<=r.siS||SL  o 


RD621  F3"8^«^''°^-f:l 


THE  LIBRARIES 


Mttkal  Hihvavv 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/technicofmodernoOOferg 


THE  TECHNIC  OF 


MODERN  OPERATIONS  FOR  HERNIA 


BY 

ALEXANDER  HUGH  FERGUSON,  M.B.,  M.D.,  CM.,  F.T.M.S. 

Commander  of  the  Order  of  Christ  of  Portugal ;  Professor  of  Clinical  Sur- 
gery, Medical  Department  of  the    University  of  Illinois ;  Professor  of 
Surgery  at  the   Chicago  Post-Gradnate  Medical  School ;  President 
of  the  Chicago  Hospital ;   Surgeon  to   the   Chicago  and  Post- 
Graduate  Hospitals ;   Fellow  of  the  International  Surg- 
ical  Association,    American    Surgical    Association, 
Chicago  Surgical  Society,  etc. ,  etc. ,  Chicago,  III. 


Illustrated  by  Reproductions  of  Original 
Drawings  from  the  Author's  Collection 


CHICAGO: 

CLEVELAND  PRESS 
1907 


/9oq 


Copyright  1907 

BY    THE 

CLEVELAND    PRESS 

CHICAGO 


THIS  BOOK 

IS 

DEDICATED 

TO 

HON.  DR.  JOHN  H.  O'DONNELL 

OF 

WINNIPEG,    MANITOBA,    CANADA 

IN   GRATEFUL    REMEMBRAKCE    OP 

ASSISTANCE     GIVEN     THE     AUTHOR 

BOTH  AS   A   STUDENT   AND 

PRACTITIONER   OF 

MEDICINE 


PREFACE. 

Believing  that  there  is  room  for  a  book  on  hernia  which  presents  onl\ 
the  purely  surgical  phase  of  the  subject,  the  author  has  prepared  this  work. 
All  discussion  of  etiology,  symptoms,  diagnosis,  prognosis  and  treatment 
other  than  surgical  has  been  omitted  (because  this  can  be  found  in  all  text- 
books on  surgery),  and  there  has  been  gathered  together  here  the  re- 
sults of  twenty  years  of  active  work  in  surgery.  These  years  have  been  of 
great  value  to  the  experience  of  the  author,  and  in  the  hope  that  others  may 
derive  some  small  benefit  therefrom  he  has  set  forth  the  following  pages. 
He  bespeaks  for  this  work  the  kindly  consideration  which  his  previous 
writings  have  received  at  the  hands  of  an  indulgent  profession. 

ALEXANDER  HUGH  FERGUSON. 


TABLE  OF  CONTENTS. 

PART  I. 

CHAPTER  I. 

Page. 
General  Considerations  and  Classification   g 

CHAPTER  n. 

The  Technic  of  Operations  for  Hernias   30 

CHAPTER  HI. 
Instruments  Used  in  Hernia  Operations    j9 

CHAPTER  IV. 
Materials  Used  for  Hernial  Operation  (Ferguson)    ■ 45 

CHAPTER  V. 
The  Chicago  Hospital  Operating  Room  Technic   (Ferguson)    52 

CHAPTER  VL 
Indications  for  Operation  58 

CHAPTER  VII. 
Preparation  of  the  Patient  y^ 

CHAPTER  VIIL 
Surgical    Bacteriology    81 

CHAPTER  IX. 
Infection 89 

CHAPTER  X. 
Sterilization  and  Disinfection   100 

CHAPTER  XI. 
Antiseptics  and  Disinfectants    109 

CHAPTER  XII. 
Sterilization  of  Catgut   123 

CHAPTER  XIII. 
The  Wound    130 

CHAPTER  XIV. 
Treatment  of  Wounds  144 

CHAPTER  XV. 
Complications  Incident  to  the  Relief  of  Hernia 149 

CHAPTER  XVI. 
Complications  Incident  to  the  Relief  of  Hernia  (continued)    166 

CHAPTER  XVII. 
General  Complications  Found  at  the  Operation   194 

CHAPTER  XVin. 

Results  of  Hernia  Operations 200 

CHAPTER  XIX. 

Results  of  Operations  for  Strangulated  Hernia   209 

CHAPTER  XX. 
Results  from  Ferguson  Method  215 


6  TABLE   OF     CONTENTS, 

PART  II. 

CHAPTER    I. 
Operations  for  Inguinal  Hernia  '. ^25 

CHAPTER    n. 
Operations  for  Inguinal  Hernia  (continued)    25S 

CHAPTER   HI. 
Operations  for  Inguinal  Hernia  (continued)    265 

CHAPTER    IV. 
The  Typic  or  Anatomic   (Ferguson)    Operation  280 

CHAPTER   V. 
Radical  Cure  of  Femoral  Hernia  289 

CHAPTER   VI. 
Radical  Cure  of  Umbilical  Hernia   304 

CHAPTER  VII. 

Repair  of  Large  Defects  in  Abdominal  Wall  3^5 

CHAPTER  VIII. 
Diaphragmatic  Hernia   318 

CHAPTER   IX. 

Internal  and  Inferior  Hernias    324 

CHAPTER   X. 
Strangulated   Hernia    336 

CHAPTER   XL 
Hernia  in  Infants    -. 343 

CHAPTER  XII. 
Unusual  Forms  of  Hernia  345 

CHAPTER  XIII. 
Local  Anesthesia  in  Hernia  Operations  358 


ILLUSTRATIONS. 


Opposite  page 
PLATE    I. — Interstitial    Hernia,    Oblique    Inguinal    Hernia,    Epigastric    Hernia, 

Direct   Inguinal   Hernia,   Femoral   Hernia    lo 

PLATE  II. — Inguinal  Hernia,  Femoral  Hernia,  Obturator  Hernia   i6 

PLATE  HI.— Petit's  Triangle,  Braun's  Space,  and  the  Anatomy  of  Sciatic  Hernia    22 

PLATE  IV.— Sliding  Hernia  of  the   Sigmoid    26 

PLATE  V. — Sliding  Hernia  of  the  Sigmoid — laid  open   .' 30 

PLATE  VI. — Inguinal  and  Ventral  Hernia  with  Suprapubic  Vesical  Fistula   ....     34 

PLATE  VII. — Ventral  Hernia  Following  Rupture  of  Rectus  Muscle 40 

PLATE  VIII. — Posterior  Hernia  through  Duodeno-jejunal  Fossa 46 

PLATE  IX. — Pericardial  Diaphragmatic  Hernia  of  the  Omentum   54 

PLATE  X. — Diaphragmatic  Hernia 60 

PLATE  XI.— Ischiatic  Hernia r. 66 

PLATE  XII.— Anatomical   Parts    74 

PLATE  XIII. — Diagrammatic  frontal  section  through  the  pelvis   82 

PLATE  XIV. — Femoral  Hernia.     Internal,  Anterior,  External   90 

PLATE  XV. — Congested  Hernia — 2  hours    94 

PLATE  XVI. — Congested  Hernia — ^4  days 102 

PLATE  XVIL— Inflamed  Hernia    ] no 

PLATE  XVIII.— Ulcerated  Hernia 116 

PLATE  XIX. — Gangrenous  Hernia  124 

PLATE  XX. — Gangrenous    (Littre's)    Hernia   130 

PLATE  XXI.— Instruments    134 

PLATE  XXII.— Instruments    ; 138 

PLATE  XXIIL— Incisions   144 

PLATE  XXIV— Incisions 150 

PLATE  XXV. — Macewen's  Operation  for  Inguinal  Hernia 154 

PLATE  XXVI. — Bassini's  Operation  for  Inguinal  Hernia  160 

PLATE  XXVII. — Kocher's  Operation  for  Inguinal  Hernia — second  step    168 

PLATE  XXVIII. — Kocher's  Operation  for  Inguinal  Hernia — fourth  step  174 

PLATE  XXIX. — Halsted's  Operation  for  Inguinal  Hernia  180 

PLATE  XXX. — Halsted's  Operation  for  Inguinal  Hernia  184 

PLATE  XXXI.— Halsted's  Operation  for  Inguinal  Hernia 188 

PLATE  XXXII. — Halsted's  Operation  for  Inguinal  Hernia  194 

PLATE  XXXIII. — Halsted's  Operation  for  Inguinal  Hernia 200 

PLATE  XXXIV. — Fowler's  Operation  for  Inguinal  Hernia   204 

PLATE  XXXV. — Fowler's  Operation  for  Inguinal  Hernia  210 

PLATE  XXXVI. — Fowler's  Operation  for  Inguinal  Hernia 216 

PLATE   XXXVIL— Parks'   Autoplastic   Suture    220 

PLATE  XXXVIII. — Bassini's  Operation  for  Inguinal  Hernia  with  Imbrication  of 

Structures    226 

PLATE  XXXIX. — McArthur's  Autoplastic  Suture  used  in  Bassini's  Operation  . .  230 
PLATE  XL. — McArthur's  Autoplastic  Suture  used  in  Bassini's  Operation 234 


8  ILLUSTRATIONS. 

PLATE  XLI. — M.  L.  Harris'  aluminum  bronze  wire  suture  used  in  Ferguson's 

operation    ^3^ 

PLATE  XLIL— Davison's  Removable  Silkworm  Gut  Suture  242 

PLATE  XLIIL— Showing  Deficiency  of  Internal  Oblique  at  Poupart's  Ligament.  246 

PLxA.TE  XLIV. — Ferguson's  Operation  for  Liguinal  Hernia 250 

PLATE  XLV. — Ferguson's  Operation  for  Inguinal  Hernia  254 

PLATE  XLVL— Fergtison's  Operation  for  Inguinal  Hernia    260 

PLATE  XLVII. — Diagram  of  the  position  of  the  transplanted  rectus  muscle,  dem- 
onstrating the  slight  change  in  the  direction  of  its  fibers. — Bloodgood's  oper- 
ation      266 

PLATE  XLVIII. — Ferguson's  Operation  for  Inguinal  Hernia   270 

PLATE  XLIX. — Ferguson's  Operation  for  Inguinal  Hernia 274 

PLATE  L. — Ferguson's  Operation  for  Femoral  Hernia 284 

PLATE  LI.— Fabricius'  Operation  for  Femoral  Hernia   290 

PLATE  LII. — Fabricius'  Operation  for  Femoral  Hernia 294 

PLATE  LIIL— Ochsner's  Operation  for  Femoral  Hernia 300 

PLATE   LIV.— Mayo's    Operation    for   UmbiHcal    Hernia    304 

PLATE  LV.— Mayo's  Operation  for  Umbilical  Hernia   310 

PLATE  LVI. — Large  UmbiHcal  and  Post-operative  Ventral  Hernias  318 

PLATE  LVIL— Blake's  Operation  for  Umbilical  Hernia  Completed   324 

PLATE  LVIII. — Ferguson's  Modification  of  Blake's  Operation  in  Suitable  Cases  330 
PLATE  LIX. — Ferguson's  Modification  of  Blake's  Operation  in  Suitable  Cases.  .   336 

PLATE  EX.— Final  Result  of  Operation  for  Umbilical  Hernia  346 

PLATE  LXL— Hernia  Into  Ileo-cohc  Fossa  350 

PLATE  LXII. — Loop  of  jejunum  into  lesser  cavity  of  omentum  354 


PART  I. 

CHAPTER  1. 

GENERAL  CONSIDERATIONS  AND  CLASSIFICATION. 

A  hernia  or  rupture  is  the  protrusion  of  any  viscus  from  the  cavity  in 
which  it  is  normally  contained.  The  term  is  usually  applied  to  protrusions 
of  abdominal  and  pelvic  viscera,  although  organs  situated  in  otiier  cavities 
may  become  herniated.  The  author  vrill  limit  his  discussion  of  hernia  en- 
tirely to  the  abdominal  variety. 

The  hernia  may  be  a  congenital  or  an  acquired  one.  Its  protrusion  may 
occur  through  openings  in  the  abdominal  wall,  which  were  present  in  fetal 
life  and  failed  to  close  at  birth,  as.  for  instance,  the  umbilicus  and  the 
funicular  process  of  the  peritoneum.     These  are  congenital  hernias. 

The  protrusion  also  may  occur  at  points  where  the  abdominal  wall 
is  weaker  than  elsewhere,  such  as  the  inguinal  region,  where  the  spermatic 
cord  passes  through  the  inguinal  canal;  at  the  umbilicus,  where  the  musck 
tissue  is  naturally  deficient :  in  the  femoral  region,  where  the  large  vessels 
and  nerves  pass  out  of  the  pelvis;  and  at  other  points  where  there  is  a 
normal  diastasis  of  muscle  fibers,  the  space  being  bridged  over  by  connec- 
tive tissue  only,  as  in  Petit's  triangle,  between  the  latissimus  dorsi  and  the 
external  oblique  muscles,  and  in  the  diaphragm.  Hernias  occurring  at  these 
points  are  of  the  acquired  variety. 

The  traumatic  hernias  or  ruptures  occur  at  points  in  the  abdominal 
wall  that  have  been  weakened  as  the  result  of  operation  or  trauma.  Her- 
nias following  abdominal  sections  and  appendectomies  are  well-known  ex- 
amples of  this  variety  of  hernia.  When  a  viscus  protrudes  through  one  of 
these  weak  spots  in  the  abdominal  wall,  it  pushes  before  itself  the  parietal 
peritoneum  and  the  various  layers  of  tissue  constituting  the  abdominal  wall 
at  that  particular  point;  but  the  innermost  layer  invariably  consists  of  a 
pouch  of  thin  parietal  peritoneum  which  is  known  as  the  sac  of  the  hernia. 

The  sac  is  usually  pear-shaped  or  pyriforni,  although  it  mav  be  mxulti- 
locular.  or  constricted,  the  so-called  hourglass  sac  (en  bissac}.  Irregular- 
shaped  sacs,  double  sacs,  invaginated  sacs  and  sacs  having  diverticula  are 
also  met  with  occasionally.  The  form  of  the  sac  depends  in  part  on  its 
contents  and  in  part  on  the  duration  of  the  hernia,  its  location  and  the 
presence  and  extent  of  adhesions.  On  the  other  hand  the  sac  may  be  absent, 
although  this  .'occurs  only  in  the  rarer  forms  of  hernia,  such  as  the  dia- 
phragmatic, the  foraminal,  in  hepatocele.  nephrocele,  etc.,  where  the  viscus 
has  only  a  partial  investment  of  peritoneum,  and  is  either  parth^  or  w-bolly 


10  GENERAL   CONSIDERATIONS   AND   CLASSIFICATION 

outside  of  it;  or  when  the  hernia  occurs  through  a  sht  in  the  peritoneum. 
When  the  sac  has  ruptured  it  is  sometimes  difficult  to  find  it,  and  such 
hernias  may  be  diagnosed  wrongly  as  having  no  sac. 

The  constricted  part  of  the  sac,  the  part  that  is  engaged  in  the  hernial 
orifice,  is  known  as  the  neck  of  the  sac.  The  part  beyond,  the  larger,  dis- 
tended part,  is  called  the  fundus  or  the  body  of  the  sac.  The  coverings  of 
the  sac  are  the  tissues  outside  of  it,  and  they  vary  with  the  site  of  the 
hernia. 

The  contents  of  the  sac  also  vary  (see  ClassHication).  Every  viscus  in 
the  abdominal  cavity  has  been  found  to  form  the  whole  or  a  part  of  the 
contents  of  the  hernial  sac.  The  small  intestine  and  omentum,  and  then 
parts  of  the  large  intestine,  are  most  often  found  to  form  the  contents  of 
the  sac.  Intra-abdominal  pressure  is  an  important  factor  in  determining 
not  only  the  occurrence  of  a  hernia,  but  also  the  contents  of  the  sac.  The 
size  of  the  opening  is  also  an  important  etiologic  factor  that  must  be  reck- 
oned with  clinically.  It  is  evident  that  a  large  viscus  cannot  protrude 
through  a  small  opening  until  the  intra-abdominal  pressure,  exerted  for  a 
sufficiently  long  period  of  time,  has  converted  the  small  opening  into  a 
large  one. 

Patent  fetal  processes,  weak  spots,  and  intra-abdominal  pressure  are 
the  factors  of  paramount  importance  in  the  production  of  hernia.  When 
the  hernial  sac  is  closed  by  adhesions  at  its  ring,  it  may  be  empty.  It  is 
then  usually  converted  into  a  cyst  containing  serous  fluid. 

There  is  no  race  or  class  of  people  that  is  free  from  rupture.  It  has 
been  shown,  however,  that  hernia  occurs  most  often  among  the  Portuguese 
and  Spaniards,  while  the  United  States  Indians  are  least  often  the  subjects 
of  hernia.  As  mentioned  above,  hernias  are  met  with  early  in  life  (in 
fact  the  child  may  be  born  with  a  hernia),  and  very  late  in  life,  but  hernia 
occurs  most  frecjuently  during  the  active  period  of  life. 

Various  writers  have  endeavored  to  ascertain  the  prevalence  of  hernia 
among  certain  peoples  by  studying  the  records  of  schools,  workhouses,  in- 
firmaries, and  recruiting  offices,  but  inasmuch  as  many  suffering  from 
hernia  never  apply  for  relief,  it  has  been  impossible  to  establish  exactly  the 
percentage  of  occurrence.  It  was  estimated  by  Marcy  that  from  one-eighth 
to  one-sixteenth  of  the  human  race  is  afflicted  with  hernia.  From  the  tables 
of  the  late  J.  H.  Baxter.  Surgeon-General,  U.  S.  A.,  we  learn  that  of  334., 321 
recruits,  substituted,  drafted  and  enrolled  men  of  various  nationalities  ex- 
amined, 16,901  were  rejected  on  account  of  hernia.  Of  this  number,  over 
half  (8,598)  had  right  inguinal  hernia.  Malgaigne  estimated  that  in  France 
3.6  per  cent,  of  the  total  population  was  ruptured ;  while  Berger  claims 
that  in  Paris  only  .44  per  cent,  are  ruptured. 

Hernia  occurs  more  often  in  the  male  than  in  the  female,  the  percentage 
of  frequency  varying  from  3  to  5.  ]\Ir.  Kingdon,  of  London,  stated  that 
there  are  6.y  per  cent,  of  males  ruptured  to  i  per  cent,  of  'females. 

Many  interesting  points  in  connection  with  the  etiology  and  occur- 
rence of  hernia  might  be  dwelt  on  in  this  connection,  but  it  is  not  the  in- 
tention of  the  author  to  do  more  than  to  call  attention  to  a  few  of  the  more 


PLATE   I. 

I.  Interstitial  Hernia.    2.  Oblique  Inguinal  Hernia.     3.  Epigastric  Eler- 
nia.    4.  Direct  Inguinal  Hernia.     5.  Femoral  Hernia. 

(Author's  Case.) 


GENERAL    CONSIDERATIONS   AND   CLASSIFICATION  1 3 

essential  points,  inasmuch  as  this  v/ork  is  not  designed  to  discuss  the  cHn- 
ical  history  of  hernia,  but  rather  the  operations  for  the  rehef  and  cure 
of  hernia. 

CLASSIFICATION. 

In  attempting  to  make  a  classification  of  abdominal  hernias,  one  is 
confronted  at  the  outset  by  the  fact  that  up  to  the  present  no  one  has  made 
a  classification  which  is  o"f  any  marked  service  to  the  clinician  or  to  the 
student.  There  are  so  many  varieties  of  hernia  and  combinations  of  differ- 
ent kinds  that  it  seems  almost  hopeless  to  undertake  to  make  any  sort  of 
classification  that  would  be  of  use  to  anyone. 

It  is  customary  to  refer  to  hernias  as  being  either  congenital  or  ac- 
quired. That  is  a  classification  based  on  etiology.  It  cannot  be  subdivided. 
Then  hernias  are  divided  into  inguinal,  femoral,  ventral,  diaphragmatic,  etc., 
making  it  incumbent  on  the  physician  to  memorize  the  various  forms  of 
the  aflr'ection  without  any  systematic   attempt  at  classification. 

In  presenting  the  following  arrangement,  the  author  has  divided  her- 
nias of  the  abdomen  and  its  walls  wdth  reference  to  their  topography  into 
1  Anterior,  II  Posterior,  III  Superior,  IV  Inferior,  V  Lateral,  and 
VI  Internal.  This  classification,  although  new,  possesses  the  recom.men- 
dation  of  being  exceedingly  simple  and  withal  logical.  It  is  an  anatomic 
classification.  To  the  best  knowledge  of  the  author  no  other  concrete  and 
complete  classification  of  abdominal  hernias  has  been  made ;  and  the  one 
here  ofl:ered  may  be  somewhat  crude  and  open  to  improvements.  How- 
ever, it  will  serve  as  a  guide  for  future  attempts  at  classifying  these 
hernias. 


14 


GEXERAL   CONSIDERATIONS   AND   CLASSIFICATION 


(Direct.  Throua-h  fyt         w  4.-  •  r,      e   ■.■,-.       t.   , 

XT  V,     uj       Internal   passes  to  inner  Side  of  obliterated 

Hesseibach  s  ,  ^   •         ^        \ 

I      trian^^le      (in--|  hypograstric  artery). 

I       ternal     ingui-  | 
nal  fossa). 


Ing-uinal(-upra- 
pubic)  Hernia 
into  inguinal 
canal, through 
internal  and 
external  fossa 


Oblique  (through 
internal 
abdom  in  a  1 
ring), 

Pre-inguinal      ( 


Labial 


External   (passes  to  outer  side  of    hypo- 
I  gastric  artery). 

j  Congenital. 

I  Acquired. 

]  Infantile  (behind  the  funicular  process  of 

I  the  peritoneum). 

[Interstitial. 

interstitial,  sac  protrudes  external  to 
inguinal  canal;  mouth  situated  near  internal  abdoin- 
inal  ring) . 

Sliding   (hernia  without  a  peritoneal   sac,  e.g.,  cecum  and 
sigmoid). 

Cruro-properitoneal  (Kronlein's). 
\  Anterior. 
/  Posterior. 
Parainguinal  [Bruggiser's  preperitoneal). 
Intra-iliac   (hernia  of   iliac  fascia  in  internal  iliac  fossa). 
Inguino-interstitial     (Govrand's    or    Boyer's  —  hernia    not 
passed  beyond  external  abdominal  ring). 
^Scrotal  (contents  occupying  the  scrotum). 
j'Saphenous  (Beclard's — through  the  saphenous  opening). 
I  Anterior  (Velpeau's — in  front  of  vessels). 
Femoral       (cru-  j  Posterior  (behind  vessels). 
ral)       Hernia  !  y    ,  ,  ,.  -^r 

into      femoral i  internal  (inner  side  of  vessels). 

canal.  1  Pectineal  (Clo:iuet — behind  pectineus  muscle) 

I  Lausier's    (through    Gimbernat's  ligamem). 
I  Ascending  subcutaneous. 
Inguino  crural  (Holthouse— combined  femoral  and  inguinal.) 
Anterior  retroperitoneal  (Treves — sac  lies    along    ilio-psoas  muscle,   inward 
toward  pelvis  and  upward  from  internal  ring). 

Congenital. 
Acquired. 
Ventral-^  Median:  Linea  alba  hernia,  congenital  and  acquired. 

•  (  Lateral:  Linea  semilunaris  hernia,  congenital  and  acquired. 
Urachal  (into  urachu  ) 
Umbilical    (om-  f  Supraumbilical. 

phalocele).  |  Annular  (paraumbilical). 

Protrusion   of  ^  ^^      .      ,        ,        ,, 

bowel      o  r  i  ^"^^'^"'^^  ^'^o'"*^)- 

omentum       at  '  In^raumbilical  (coeliocele). 

navel.  i  Interstitial  (a)  subcutaneous  (b)  subperitoneal. 

Intersigmoid  (protrusion  ;-.t  intersigmoid  fossa  in  sigmoid  meso-colon). 
Sacro-rectal,  also  inferior. 

1  Enterocele  into  lower  fossa  duodenojejunalis -j  !^^^^'-' 

J    Duodenojejunal  ]  t:.    .  ,      ■    . 

-"  I  Lnterocele  into  upper  fossa,    into  the   lesser  cavity  of  the 

'-         peritoneum. 

Retrocecal  (small  intestine  beliind  cecum  or  subcecal). 

Ileo-cecal  (into  ileocecal  fossa  and  extends  behind  the  cecum). 

Ileo-colic  (into  ileo- colic  fossa). 


Epigastric  (just   below   xyphoid    cartilage) 


GEXERAL    COXSIDERATIOXS    AXD   CLASSIFICATIOX 

^    I    Lumbar    (emerg-ing  from  back  of  abio-  /  Cong-enital  (Petit's  triang-le). 
n>    I  men  between  pelvis  and  last  rib).  \  Acquired. 


H  ■{    Hepatocele  (hernia  of  the  liver) 
Splenocele  (hernia  of  spleen). 
Nephrocele  (hernia  of  kidney). 


c    j 

^     I    Diaphragmatic  (through  the  diaphragm). 

^     1    (Phrenic). 


Perineal  (ischiorectal — rests  on  floor  of  pelvis). 

Obturator  (infrapubic — into  obturator  foramen). 

Ischial ic  (sciatic —  through  sacrosciatic  foramen). 

Sacrorectal — due  to  defective  ossification  of  sacrum  (also  posterior). 

^r      ■      1  i  Rectovaginal, 
jv         Vaginal  .  ^ 
S     J  '  Cystovaginal  (bladder  into  vagina). 

j  Vesico-rectal  (bladder  into  rectum). 

Vesical  -^  Vesico-inguinal  (bladder  into  inguinal  canal). 

Vesico  femoral  (bladder  into  femoral  canal). 

Proctocele  (may  be  mistaken  for  postanal  duct). 

Hernia  into  Douglas'  Pouch. 


r  Foraminal  (Winslowian — into  lesser  cavity  of  the  peritoneum  through  foramen 

H  I            of  Win^low). 

^  I    Mesenteric  (Cooper's — retroperitoneal). 

Oi  -|            (Passage  of  ponion  of  bowel  through  congenital  weak  spot  in  mesentery). 

^  I    Diverticular  (hernia  through  the  mesentery  of  Meckel's  diverticulum). 

12;  Omental  (protrusion  of  a  knuckle  of  bowel  through  a  congenital  weak  spot  in 

'"'  L           omentum. 

CONDITION  OF  SAC 

En  bissac  (hourglass). 

Multilocuiar  (Cooper's  or  Hesselbach's  femoral). 

Lipomatous. 

Sac  absent  (sliding). 

Double  Sac. 
CONTENTS   OF  SAC 

Diverticulum — Meckel's. 

Sigmoid. 

Rectum. 

Cecum. 

Appendix. 

Colon. 

,  Small  intestine   \  [^J  ^""'[^.^  1°°P'         ,  ,^  .,,     ,       ' 
I  (  (b)  portion  of  bowel  (Littre). 

Epiplocele  (lipocele,  steatocele,  fat,  omentum). 

Entero  epiplocele  (intestine  and  omentum). 

Gastrocele  (stomach). 

Cystocele  (bladder). 

Hysterocele  (uterus):  ]  G-^avid. 

(  Non-gravid. 
Hepatocele  (liver). 
Oopherocele  (ovary). 

Tubocele  (oviduct)  ^  ^^o^mal  tube. 
(  Gravid  tube. 
Splenocele  (spleen). 
Nephrocele  (kidney). 
Pancreccele  (pancreas). 


Enterocele  (intestine); 


i6 


GENERAL   CONSIDERATIONS   AND   CLASSIFICATION 


Tumor 


Hydatidocele  (hydatid  cyst). 
Dermoidocele  (dermoid  cyst). 
Benign. 
Ma  ignant. 
Seminal  vesicles. 

i  Blood  (sanguinocele). 
Fluid  -\  Pus  (puracele). 

(  Serum  (hydrocele). 
Aneurysmocele  (aneurysm). 
Sarcocele  (muscle). 

[   Inflamed. 

I    Incarcerated  (comp'ete  obstruction  of  bowel) 

CA,  1        J  ,         ^  ■  4.  A\  \  Complete 

I    Strangulated  (constricted)  -^  incomplete 

Cystic  (cystocele). 

Displaced  (between  layers  of  abdominal  wall). 

Concealed  (not  perceptible  on  palpation). 

Reducible. 

Irreducible. 

Encysted  (Cooper's  sac  is  pu-hed  into  congenital  opening  in  tunica 

vaginalis). 
Complete  (sac  and  contents  passed  through  orifice). 
Incomplete  (Bubonocele — sac  does  not  protrude   beyond    external 

abdominal  ring). 


CLINICAL 
VARIETIES 
OF  HERNIA 


Richter's. 
Littre's. 


Beclard's 
Berketts 
Boyer  s 
Bruggiser's 
Cloquet's 

Cooper's 

Gerdy's 

Goyrand's 

Hesselbach's 

Holthou«e's 

Kroenlein's 

Laugier's 

Linhart's 

Littre's 

Malgaigne's 

Partridge's 

Petit's 

Richter's 

Treves' 

Velpeau's 


EPONYMIC  HERNIAS 
through  the  saphenous  openirg). 

into  vaginal  process  of  peritoneum — coming  on  late  in  life), 
intrainguinal — Goy  rand's) 
properitoneal  or  parainguinal). 
pectineal — behind  pectineus  muscle). 

1.  Crural,    with  protrusion  through  the  superficial  fascia. 

2.  Congenital,  in  tuaica  vaginalis, 
adumbilical). 
inguino-interstitial — Boyer 's). 

crural,  with  protrusion  through  the  cribriform  fascia). 

inguino-crurai). 

having  both  parietal  and  inguinal  sacs,    cruro-properitonea  ). 

crural    throuijh  Gimbernat's  ligament). 

retroperitoneal,  parietal — a  properitoneal  hernia). 

a  portion  of  ileum    strangulated). 

congenital — inguinal). 

femoral,  anterior  to  or  to  the  outer  side  of  the  femoral  vein). 

lumbar). 

partial  enterocele). 

an'erior  retroperitoneal — sac  has  made  its  way  upward  from 
internal  ring  along  ilio-psoas  muscle,  or  in  ..  ard  toward  pelvis. 

(femoral,  anterior  to  vessels. 


PLATE  11. 

I.  Inguinal  Hernia.     2.  Femoral  Hernia.     3.  Obturator  Hernia. 

(Author's  Case.) 


GENERAL   CONSIDERATIONS   AND   CLASSIFICATION  IQ 

CONTENTS  OF  SAC. 

Bladder.  Quite  a  number  of  instances  have  been  recorded  in  which 
a  diverticulum  or  pouch  of  the  bladder  formed  the  whole  or  a  part  of  the 
contents  of  the  hernial  sac.  Personally,  I  have  always  felt  that  it  is  only 
by  accident  that  the  bladder  is  found  in  the  canal,  either  because  of  care- 
less manipulation  by  the  operator,  or  because  of  the  formation  of  adhesions 
which  draw  upon  the  bladder.  However,  I  am  free  to  admit  that  the  blad- 
der, or  a  diverticulum  thereof,  has  been  found  inside  the  canal  and  must 
be  considered  as  a  possible  content  of  the  hernial  sac. 

Charles  Adams  (Clinical  Review^  Vol.  12,  No.  4)  reports  an  instance 
where  the  tumor  was  quite  distinct  from  the  testicle,  was  easily  reducible, 
and  presented  all  the  indications  of  hernia  without  any  vesical  symptoms. 
On  incising  what  was  supposed  to  be  the  sac,  he  encountered  and  opened, 
inadvertently,  a  diverticulum  of  the  bladder.  This  diverticulum  which  was 
firmly  adherent  to  the  cord  and  canal,  was  cut  away,  its  walls  being  too 
thin  to  suture,  and  the  opening  into  the  bladder  was  closed  by  a  continuous 
suture. 

S.  C.  Plummer  (Jour.  Am.  Med.  Ass'n.,  July  22,  1905)  reported  a 
hernia  of  the  bladder  complicating  an  inguinal  hernia,  with  an  undescended 
testicle  on  the  left  side.  While  operating  for  the  hernia,  he  discovered  a 
second  sac.  He  opened  it  and  much  to  his  surprise  found  it  to  be  the 
bladder.  The  wound  in  the  bladder  was  sutured  and  primary  union  took 
place. 

Harrington  (Annals  of  Surgery,  September,  1900)  cites  a  case  of 
hernia  of  the  bladder  tlirough  the  pelvic  outlet  caused  by  the  traction  of  a 
large  subperitoneal  fibroma  of  the  uterus.  The  bladder  was  restored  to 
the  pelvis,  the  tumor  was  removed,  and  the  uterus  was  utilized  to  occlude 
the  opening,  its  appendages  haidng  first  been  removed. 

A  rather  unique  case  is  reported  by  Collier  (Lancet,  June  6,  1903). 
The  patient  was  being  treated  for  a  double  reducible  congenital  hernia. 
A  truss  failing  to  retain  the  hernias  an  operation  became  necessary.  On 
the  right  side  the  sac  was  found  to  contain  the  urinary  bladder,  and  on  the 
left  side  it  contained  the  cecum  and  appendix. 

In  another  instance  reported  by  C.  E.  Ingbert  (Jour,  of  the  Amer. 
Med.  Ass'n.,  Aug.  4,  1906),  the  patient  had  a  right  inguinal  hernia  for 
seven  years,  but  kept  it  in  place  with  a  truss.  It  finally  became  irreducible. 
The  tumor  mass  was  three  inches  long,  two  inches  wide,  and  one  inch  in 
■diameter  ventro-dorsally.  It  was  rather  painful  when  pressed  on  or  moved. 
In  the  hernial  canal  was  found  a  hard  mass  about  the  size  of  an  egg,  which 
proved  to  be  continuous  with  the  bladder.  It  was  pushed  back  and  the 
canal  closed. 

It  will  be  seen  from  these  recorded  cases  that  unless  the  patient  ex- 
hibits symptoms  of  cystitis  or  distress  referable  to  the  bladder,  it  is  almost 
impossible  to  make  a  diagnosis  of  cystocele.  F.  Karewski  (Archiv  f.  JClin. 
Chir.,  Vol.  75)  reports  5  cases,  in  one  of  which  he  succeeded  in  making  a 
clinical  diagnosis.  In  two  cases  the  diagnosis  w^as  confirmed  by  the  cvsto- 
scope.     In  one  case  the  condition  was  not  recognized  until  the   sac   was 


20  GENERAL   CONSIDERATIONS   AND   CLASSIFICATION 

opened,  and  in  the  remaining  case  the  bladder  was  injured  accidental}}-,  its 
presence  in  the  canal  not  having  been  suspected.  Three  of  the  cases  were 
crural  hernias  occurring  in  women.  Karewski  states  that  no  case  of  con- 
genital hernia  of  the  bladder  has  ever  been  reported.  In  250  cases  of 
cvstocele  reported  the  bladder  was  found  forming  a  portion  of  the  con- 
tents of  the  sac  of  inguinal  and  crural  hernias  in  five  instances  of  the 
former  to  one  of  the  latter.  H.  J.  Curtis  (Brit.  Med.  Jour.,  July  11,  1903) 
observed  only  one  case  in  two  years. 

Xo  matter  whether  or  not  hernia  of  the  bladder  is  a  genuine  hernia, 
the  fact  that  it  may  be  found  in  the  canal  makes  it  incumbent  on  the  oper- 
ator to  exercise  the  greatest  care  when  cutting  down  on  the  sac  of  a  her- 
nia, because  of  the  possibility  of  finding  a  pouch  of  the  bladder  in  the 
canal. 

Appendix — Enterocele.  All  parts  of  the  intestinal  tract  may  be 
found  within  the  sac  of  a  hernia.  Of  course,  the  small  intestine,  particu- 
larly the  ileum,  is  usually  contained  in  the  sac.  In  3,054  cases  of  hernia  the 
appendix  was  found  in  the  sac  58  times,  or  once  in  about  33  cases.  Of 
100  cases  of  appendicular  femoral  hernia,  81  occurred  in  women  and  7  in 
men;  no  sex  being  mentioned  in  12.  The  yoimgest  patient  was  19  years  of 
age,  the  oldest  87.  More  than  one-half  of  the  patients  were  over  fifty  years 
old,  and  over  85  per  cent,  were  past  forty. 

J.  B.  Hall  (Brit.  Med.  Jour.,  June  28,  1902)  reports  a  case  of  per- 
foration of  the  appendix  within  the  hernial  sac,  occurring  in  a  man  23 
years  of  age,  who  five  days  before  his  admission  to  the  hospital,  while  lift- 
ing a  heavy  sack  of  flour,  was  seized  with  a  sudden  acute  pain  in^  the  right 
groin.  When  operated  ten  days  after  the  accident,  the  sac  was  found  to 
contain  a  mass  of  intestine  together  with  lymph,  disorganized  blood  clot  and 
pus.  The  appendix  presented  a  perforation  near  its  base  through  which 
exuded  pus,  fecal  matter  and  also  two  small  concretions.  The  cecum  was 
so  infiltrated,  softened  and  septic  that  it  was  excised  and  an  anastomosis 
made  with  a  IMurphy  button.  The  patient  recovered,  the  button  being 
passed  on  the  seventeenth  day. 

C.  J.  Symonds  (Trans.  Loud.  Clin.  Soc.,  \"ol.  32)  cites  a  case  in  which 
the  appendix  occupied  the  sac  of  a  right  inguinal  hernia.  The  tip  of  the 
appendix  was  perforated  by  a  pin.  The  patient  was  a  woman,  and  the 
diagnosis  lay  between  its  being  a  piece  of  incarcerated  omentum  and  a  pro- 
lapsed ovary.  When  the  sac  was  opened  it  contained  some  serous  fluid 
and  a  hard,  elongated  swelling  looking  like  a  piece  of  omentum.  On  rais- 
ing this  mass  the  end  of  a  pin  was  exposed,  protruding  from  the  central 
swelling.  The  mass  proved  to  be  the  appendix.  The  canal  was  closed  with 
sutures  and  a  drainage  tube  inserted  into  the  superficial  part.  The  appen- 
dix occupied  a  patent  funicular  process. 

In  one  instance  cited  by  A.  C.  Wood  (Annals  of  Surgery,  May,  1906) 
the  patient,  a  woman,  aged  70,  had  a  painful,  fluctuating  swelling  in  the 
right  groin  which  was  supposed  to  be  a  suppurating  inguinal  gland.  On 
incising  the  mass.  Wood  encountered  a  small,  gangrenous,  offensive  mass, 


GENERAL   CONSIDERATIONS   AND   CLASSIFICATION  21 

which  proved  to  be  the  appendix.     It  was  contained  in  the  sac  of  a  femoral 
hernia. 

Four  years  afterwards  he  saw  another  patient  who  had  a  tumor  in  the 
right  groin,  supposedly  a  femoral  hernia.  At  the  operation  the  swelling 
was  found  to  consist  chiefly  of  serum,  but  the  sac  also  contained  the  ap- 
pendix, a  portion  of  which  was  grasped  so  tightly  at  the  neck  of  the  sac 
that  its  reduction  was  impossible  until  the  constriction  had  been  divided. 

In  1900  I  operated  on  a  man  45  years  of  age  for  a  swelling  in  his 
right  inguinal  region.  He  had  worn  a  truss  for  six  years  for  his  hernia. 
Owing  to  increased  swelling  in  this  region  the  truss  was  discarded  three 
months  before  consulting  me.  The  swelling  continued  to  enlarge  and  finally 
gave  him  discomfort  while  at  work.  The  sac  contained  nothing  but  the 
appendix  in  the  condition  of  a  retention  cyst.  The  root  of  the  appendix 
w^as  completely  occluded.  Almost  an  amputation  of  the  appendix  had 
occurred. 

Broughton  and  Hewetson  (Lancet,  June  16,  1906)  report  another  case 
of  herniated  appendix,  the  hernia  in  this  instance  being  of  the  femoral 
variety,  occurring  in  a  woman  63  years  of  age.  After  having  been  present 
for  twenty-four  years,  the  small  lump  in  the  right  .groin  showed  signs  of 
inflammation.  A  diagnosis  was  made  of  inflamed  femoral  epiplocele.  An  in- 
cision over  the  mass  was  made,  an  abscess  containing  about  two  ounces  of 
fetid  pus  and  surrounded  by  ragged,  gangrenous  walls  was  evacuated,  and 
a  pin.  incrusted  with  fecal  matter,  was  found  lying  in  the  mass.  Nothing 
resembling  a  hernial  sac  could  be  distinguished  up  to  this  point.  The  whole 
gangrenous  mass  was  isolated  down  to  the  saphenous  opening.  After  care- 
fully covering  up  the  gangrenous  area  with  gauze,  this  was  opened  and 
the  contents  were  readily  recognized  as  a  thickened  appendix  and  a  small 
mass  of  omental  tissue.  The  appendix  was  withdrawn  and  amputated  close 
to  the  cecum,  the  omental  loop  was  divided  and  both  were  pushed  just 
within  the  abdomen.  A  strand  of  iodoform  gauze  was  inserted  into  the 
femoral  canal,  partly  to  act  as  a  drain  to  the  appendical  stump,  but  chiefly 
to  protect  the  peritoneum  from  becoming  infected  from  the  gangrenous 
Scarpa's  triangle.  A  large  drainage  tube  was  passed  into  the  bottom  of 
the  wound  and  the  skin  margin  was  approximated  by  silk-worm  gut  sutures. 

My  first  (1885  J  operation  for  strangulated  hernia  proved  to  be  one 
whose  contents  was  the  appendix  and  a  portion  (Littre-like)  of  the  cecum. 
The  appendix  was  almost  ruptured,  greatly  enlarged  and  inflamed.  Its 
root  was  so  friable  that  a  pressure  forceps  applied  to  it  about  half  an  inch 
from  the  cecum  cut  it  clear  off,  allowing  fecal  matter  to  pour  over  m)- 
wound.  I  managed  to  ligate  it  with  stout  silk  leaving  the  end  long.  The 
cecum  was  adherent  to  the  internal  ring  and  I  left  it  undisturbed,  resting 
content  with  cleansing  the  wound  and  packing  it  with  iodoform  gauze.  He 
made  a  good  recovery  and  has  not  yet  needed  another  operation. 

This,  no  doubt,  was  a  case  of  appendicitis,  and  not  one  of  strangulated 
hernia,  as  I  diagnosed  it.  The  appendix  became  inflamed  while  it  was  ex- 
tending into  the  sac  of  the  hernia. 

Since   that   time   I   have   removed   the   appendix   through   the   hernial 


22  GENERAL   CONSIDERATIONS   AND   CLASSIFICATION 

opening-  in  a  considerable  number  of  cases.  Before  t3dng  ofif  the  sac  the  ap- 
pendix should  always  be  inspected.  A  very  useful  instrument  for  dragging- 
the  appendix  down  into  view  is  that  devised  by  Dr.  Barrett  (F.  21). 

Another  instance  of  the  difficulty  of  making  a  diagnosis  when  the 
appendix  is  contained  in  the  sac  of  the  hernia  is  reported  by  Macewen 
{Lancet,  June  16,  1906).  The  patient  presented  himself  for  the  relief  of 
a  strangulated  hernia  which  he  said  had  existed  for  twelve  years.  A  truss 
had  been  worn  until  two  weeks  before  the  patient  was  seen.  It  was  left  ofif 
because  the  man  began  to  sufifer  considerable  discomfort,  which  eventually 
turned  into  a  distinct  pain.  On  examination,  Macewen  found  a  large, 
pvriform  swelling  afifecting  the  right  inguinal  region  and  scrotum.  The 
scrotal  tissue  was  much  inflamed.  The  testis  appeared  to  be  fused  with  a 
mass  which  was  firm  in  consistence  and  dull  on  percussion.  No  impulse  on 
coughing  was  elicited.  The  hernia  was  not  reducible.  At  the  operation  the 
hernia  was  found  to  consist  of  the  appendix,  the  latter  being  held  in  posi- 
tion by  a  pin,  the  point  and  about  one-half  the  shaft  of  which  projected 
through  a  small  ulcerative  aperture  in  the  wall  of  the  appendix. 

A  unique  case  of  femoral  hernia  was  reported  by  S.  Castellan!  {Annals 
of  Surgery,  Dec,  1898.)  The  sac  contained  small  intestine,  cecum,  appen- 
dix, ascending  colon  and  transverse  colon.  He  also  reports  a  case  of  in- 
guinal hernia  in  which  he  failed  to  find  a  sac.  There  had  been  intermittent 
symptoms  of  strangulation,  and  one  month  before  the  hernia  appeared  an 
abscess  formed  in  this  region  and  was  opened.  What  was  thought  to  be 
the  sac  of  the  hernia  turned  out  to  be  the  lumen  of  the  bowel.  On  incising 
the  external  oblique  aponeurosis  it  was  seen  that  the  knuckle  of  bowel  ad- 
hered to  the  abdominal  wall  opposite  the  external  ring. 

R.  C.  Turck  {J our.  Aincr.  Med.  Ass'n.,  April  26,  1902)  reported  a  case 
of  hernia  of  the  cecum,  which  was  complicated  by  hydrocele  and  suppura- 
tive appendicitis.  The  appendix,  testis  and  sac  were  removed  en  masse, 
together  with  a  large  amount  of  omentum. 

Meckel's  Diverticulum. — There  is  no  end  to  the  varieties  of  hernia 
that  one  may  encounter.  R.  E.  Webster  {Annals  of  Surgery,  April,  1902) 
reports  a  case  of  hernia  of  Meckel's  diverticulum.  The  patient  had  svmp- 
toms  of  intestinal  obstruction,  but  examination  showed  a  strangulated,  left 
inguinal  hernia,  and  when  the  sac  was  opened  a  diverticulum  measuring 
three  and  a  half  inches  in  length  v/as  found  arising  from  the  ileum,  which 
was  removed. 

Liver. — Among  the  very  rare  varieties  of  hernia  are  the  following: 
A  case  of  congenital  hernia  of  the  liver  into  the  umbilical  cord  is  reported 
by  J.  W.  Bullard  {American  Medicine,  Nov.  8,  1902),  as  occurring  in  a 
male  child.  Radical  operation  was  attempted  when  the  child  was  twelve 
days  old,  but  owing  to  the  presence  of  extensive  adhesions  the  operation 
had  to  be  abandoned.     The  child  died  twenty  hours  afterwards. 

Pancreas. — Guimaraes  {Progres.  Med.,  Oct.  10,  1896)  reported  a 
case  of  hernia  of  the  pancreas  following  a  bayonet  wound.  Forty-eight 
hours  after  the  accident  the  tail  of  the  pancreas  protruded  from  the  in- 


PLATE  III. 

Petit's  Triangle,  Braun's  Space,  and  the  Anatomy  of  Sciatic  Hernia.  (After 

Sanders.) 

I.  Latissimus  dorsi  muscle.  2.  External  oblique  muscle.  3.  Petit's 
triangle.  4.  Braun's  space.  5.  Gluteus  muscle.  6.  Gluteus  maximus  muscle. 
7.  Gluteal  artery.  8.  Gluteus  minimus  muscle.  9.  Sciatic  hernia.  10.  Pyri- 
formis  muscle.  11.  Great  trochanter  12.  Sciatic  artery.  13.  Gemellus  su- 
perior muscle.  14.  Obturator  internus  muscle.  15.  Gemellus  inferior  mus- 
cle,    16,  Sciatic  nerve. 


GEXERAL   COXSIDERATIOXS   AXD    CLASSIFICATIOX  25 

•cision.  It  was  restored  to  the  abdomen  and  the  wound  closed.  The  patient 
recovered. 

Quenn  collected  6  cases  of  hernia  of  the  pancreas.  In  each  case  the 
herniated  portion  of  the  pancreas  was  cut  off.  Five  of  the  patients  re- 
covered. 

Semixal  A'^esicles. — Xogues  recently  reported  a  case  to  the  French 
Urological  Association  in  which  a  periprostatic  abscess  was  drained 
through  a  perineal  incision.  Eight  days  later,  while  straining  at  stool,  the 
patient  expelled  both  seminal  vesicles  through  the  wound. 

HERNIA  OF  FEMALE  PELVIC  ORGANS. 

Although  the  individual  surgeon  does  not,  as  a  rule,  meet  with  cases 
-of  hernia  of  the  female  pelvic  organs  very  often,  the  cases  recorded  in 
the  literature  are  quite  numerous.  Frank  T.  Andrews,  of  Chicago,  has 
made  a  very  thorough  study  of  this  class  of  hernias,  and  his  contributions 
■on  the  subject  cover  the  field  very  well. 

In  1905  (Jour.  A.  M.  A.,  Nov.  25)  he  reported  366  cases  culled  from 
the  literature,  including  a  full  report  of  four  cases  of  hernia  of  the  tube 
without  the  ovary.  He  found  46  cases  of  hernia  of  the  tube  without  the 
ovary;  80  cases  of  hernia  of  the  ovary  and  tube,.  267  cases  of  hernia  of 
the  ovary  wdthout  the  tube ;  43  cases  of  hernia  of  the  non-gravid  uterus ;  30 
cases  of  hernia  of  the  pregnant-  uterus.  Of  the  46  cases  of  hernia  of  the 
tube  alone,  2y  were  inguinal,  14  femoral,  2  obturator  and  3  not  stated.  The 
tube  alone  was  found  to  be  the  contents  of  the  inguinal  sac  in  23  cases ;  tube 
and  intestine  in  2 ;  tube  and  omentum  and  tube  and  part  of  bladder  in 
one  each.  In  eleven  cases  the  sac  contained  fluid.  Of  the  femoral  hernias 
the  tube  alone  was  contained  in  the  sac  1 1  times ;  tube  and  omentum  once ; 
tube  and  epiploon  once ;  tube  and  part  of  the  bladder  once.  In  seven  cases 
the  sac  contained  fluid. 

In  1906  {Jour.  A.  M.  A.,  November  24)  he  reported  88  cases  of  in- 
guinal hernia  containing  both  ovary  and  tube,  80  of  which  were  operated 
on.  In  18  of  these  80  cases  the  ovary  and  tube  were  returned  to  the  abdo- 
men. In  2  cases  the  ovaries  were  removed  and  the  tubes  returned  to 
the  abdomen.  A  tubal  pregnancy  within  the  hernial  sac  occurred  in  five 
instances.  In  one  case  the  uterus  was  pregnant  in  the  pelvis  while  the 
'Ovary  and  tube  were  in  the  hernial  sac.  There  was  strangulation  in  11 
cases;  twisted  pedicle  in  13  cases;  cystic  ovary  in  6;  tuberculosis  of  the 
tube  in  2,  and  sarcoma  of  the  ovary  in  one.  In  eight  cases  intestine  or 
lomentum  was  contained  in  the  sac,  and  in  two  the  appendix. 

There  were  five  cases  of  femoral  hernia  containing  both  ovary  and 
tube.  There  was  incarceration  and  strangulation,  with  operation  and  re- 
-covery  in  all. 

There  were  four  cases  of  obturator  hernia  and  two  of  ischiatic  hernia. 
Regard    (Archiv  f.   Klin.    Chir.,   A'ol.    Ixxv.   p.   425)    refers   to   four- 
teen cases  of  hernia  of  the  ovary  reported  by  Deneux  in   1814.     Of  this 
number  9  were  inguinal  hernias ;  2  were  ischiatic,  and  there  was  one  hernia 
«ach  of  the  crural,  vaginal,  and  ventral  varieties. 


26  GENERAL   CONSIDERATIONS   AND   CLASSIFICATION 

In  1 871  English  reported  38  cases,  of  which  27  were  inguinal,  9  crural, 
I  ischiatic  and  i  obturator.  In  1892  Bitzako  compiled  the  literature  of 
113  cases,  91  of  which  were  inguinal,  17  crural.  Puech  in  a  series  of  88 
cases  gives  54  congenital,  17  doubtful  and  17  acquired  cases.  English  be- 
lieves that  17  of  his  cases  were  congenital.  Bitzako  states  that  66  of  his 
series  were  congenital.  Thus  far  the  ovary  has  been  found  to  constitute 
the  contents  of  the  sac  in  4  cases  of  ischiatic  hernia. 

Lockwood  {Brit.  Med.  Jour.,  June  13,  1896)  reports  an  unusual  case 
of  hernia  of  the  ovary  that  occurred  in  an  infant  only  six  months  of  age. 
The  child  became  ill  suddenly,  and  two  days  later  there  appeared  a  swell- 
ing which  was  tender  to  touch  but  was  easily  reducible.  It  was  about 
three  inches  long  and  one  and  a  half  inches  broad.  The  skin  over  it  was 
inflamed.  There  was  no  impulse  on  crying,  but  the  child  vomited  occa- 
sionally. There  w^as  no  obstruction  of  the  bowels.  A  diagnosis  was  made 
of  strangulated  hernia  and  at  the  operation  the  sac  was  found  to  contain 
the  ovary,  the  fimbriated  end  of  the  Fallopian  tube,  and  a  grumous  fluid. 
There  were  no  adhesions  at  the  internal  ring.  The  tube  and  ovary  were 
replaced,  the  sac  was  ablated,  and  the  wound  closed.  Mr.  Owen  reported 
a  similar  case. 

P.  F.  Morf  {Annals  of  Surgery,  ]\Iarch,  1901)  reports  one  case  of 
hernia  of  the  Fallopian  tube,  without  hernia  of  the  ovary,  occurring  in  a 
woman  who  had  suffered  from  a  congenital  hernia  in  the  left  inguinal  re- 
gion. The  case  illustrates  the  extension  of  the  inflammation  from  the 
vagina  through  the  uterus  and  then  through  the  tube  into  the  sac  of  the 
hernia  where  it  caused  suppuration.  A  portion  of  omentum  was  also  found 
in  the  sac.  Of  24  cases  recorded  in  the  literature,  13  were  inguinal,  10 
crural  and  one  obturator.  Strangulation  was  present  in  14  cases.  Of  these 
six  were  inguinal,  seven  femoral  and  one  obturator. 

J.  H.  Jopson  (Annals  of  Surgery,  July,  1904)  reports  the  case  of  a 
woman,  aged  27,  multipara,  who  had  had  a  sm.all  right  inguinal  hernia  as 
long  as  she  could  remember.  It  was  of  about  the  size  of  a  walnut,  a  small^ 
hard,  painless  protrusion,  which  always  descended  when  she  was  on  her 
feet  and  disappeared  on  lying  down.  It  always  was  reducible ;  it  gave  her 
no  trouble,  and  she  never  wore  a  truss.  Suddenly,  while  washing,  a  large 
protrusion  appeared  in  the  right  groin,  accompanied  by  severe  pain.  There 
was  neither  vomiting,  constipation,  fever  or  chill.  The  swelling  then  was 
of  about  the  size  of  a  fist,  situated  in  the  right  inguino-labial  region,  coming 
from  the  external  abdominal  ring;  hard,  irreducible  and  somewhat  tender. 
A  probable  diagnosis  was  made  of  omental  hernia.  The  tumor  was  pear- 
shaped,  the  wide  end  presenting.  The  sac  was  adherent,  except  at  the  con- 
stricted base.  While  endeavoring  to  unfold  the  sac,  it  suddenly  split  longi- 
tudinally and  about  three-quarters  of  an  ounce  of  a  yellow,  odorless  pus 
escaped.  An  ovary  was  seen  to  protrude  from  the  canal  to  the  right  of 
the  neck  of  the  mass,  also  the  broad  ligament  and  tube.  It  was  then 
discovered  that  the  herniated  mass  was  the  uterus  turned  over  forward, 
the  supravaginal  portion  running  backward,  downward  and  inward  toward 
the  cervix.  The  necrotic  and  infected  condition  of  the  body  of  the  uterus 
forbade  its  reduction  and  it,  with  the  ovar}^  and  sac,  were  removed.     To  se- 


PLATE  IV. 

Sliding  Hernia  of  the  Sigmoid. 
(Author's  Case.) 


GENERAL   CONSIDERATIONS   AND   CLASSIFICATION  29 

cure  drainage,  to  exclude  the  peritoneum  and  to  close  as  far  as  possible 
the  canal,  the  pedicle  was  fastened  in  the  external  abdominal  ring,  the  pil- 
lars of  the  latter  being  sutured  with  chromicized  catgut  above,  around  and 
below  it.  A  small  gauze  wick  was  laid  over  the  stump  and  the  wound  was 
closed  in  its  deeper  portion  by  a  continuous  chromicized  catgut,  and  the 
skin  with  silkworm  gut.     The  patient  made  an  uneventful  recovery. 

Hilgenreiner  (Berliner  Klin.  Woch.,  xliii,  No.  ii)  reports  a  case 
of  inguinal  hernia  of  the  uterus,  and  refers  to  39  similar  cases  reported  in 
the  literature.  In  the  majority  of  these  cases  the  defect  was  congenital  and 
was  accompanied  by  other  anomalies.  In  four  instances  the  patients  were 
men  and  in  another  a  male  hermaphrodite.  In  eight  cases  the  uterus  was 
pregnant.  In  the  case  personally  observed  the  patient  suffered  from  mel- 
ancholia, which  subsided  completely  after  the  operation.  The  uterus  and 
right  adnexa  with  some  loops  of  intestines  were  found  in  the  hernia.  They 
were  adherent  and,  on  account  of  shock,  the  operation  was  done  in  two 
stages.  The  psychosis  developed  during  the  interval  of  about  nineteen 
months. 

In  a  case  of  hernia  of  the  female  pelvic  floor  reported  by  Keiller 
(Anier.  Jour,  of  Ohstet.,  March,  1906),  the  whole  vagina  was  everted,  the 
intravaginal  cervix  uteri  and  its  os  occupying  very  nearly  the  center  of 
the  tumor.  There  was  no  marked  erosion  of  the  vaginal  mucosa.  The 
hernia  contained  two-thirds  of  the  contracted  bladder,  the  lower  three 
inches  of  the  uterus,  and  half  of  the  urethra;  the  whole  vagina,  which  was 
completely  everted,  at  least  four  inches  of  a  much-elongated  uterus,  the 
canal,  and  5  cm.  of  rectum,  as  well  as  the  uterovesical  and  rectovaginal 
pouches  of  peritoneum.  The  fundus  of  the  uterus  was  only  slightly  lower 
than  normal. 


CHAPTER  II. 

THE  TECHNIC  OF  OPERATIONS  FOR  HERNIAS. 

The  Patient,  (a)  Physical  Condition..  Before  attempting  to  per- 
form an  operation  for  hernia,  it  is  of  paramount  importance  to  establish 
definitely  the  exact  physical  status  of  the  patient.  A  thorough  physical 
examination  should  be  made  of  the  heart,  lungs  and  other  vital  organs,  in- 
cluding the  determination  of  the  renal  functions  and  the  condition  of  the 
nervous  system.  The  patierit's  habits  and  mode  of  life  ought  also  to  be 
looked  into.  It  is  a  good  rule  to  make  it  a  routine  practice  to  conduct  this 
examination  just  as  carefully  as  one  would  in  the  case  of  an  individual  ap- 
plying for  life  insurance,  particularly  as  there  is  more  at  stake. 

There  is  no  operation  for  hernia  that  is  not  attended  by  more  or  less 
risk,  although  the  vast  majority  of  operations  are  accompanied  by  only  a 
minimum  risk,  and  do  not  endanger  life.  Some  operations  are  attended  by 
special  dangers.  These  will  be  discussed  later  on.  When  the  operation 
is  not  done  in  an  emergency,  to  save  the  life  of  the  patient,  it  is  the  duty 
of  the  surgeon  to  estimate  and  choose  between  the  danger  to  life  incurred 
by  operating  and  the  danger  to  life  if  the  hernia  is  left  uncured.  If  the 
patient  is  in  good  health,  the  danger  attending  an  operation  for  the  relief 
of  a  small,  acquired,  reducible  hernia  should  be  slight;  but  if  the  patient 
is  the  victim  of  a  chronic  nephritis,  or  some  other  equally  serious  affection, 
the  operation  might  prove  fatal.  A  form  of  hernia  that  is  attended  by  con- 
siderable operative  risk  is  the  ventral  hernia  which  follows  appendicectomy 
or  abdominal  section,  especially  when  many  adhesions  have  formed.  It 
is  here  that  the  operator  must  possess  keen  judgment  of  the  conditions 
present  and  a  full  knowledge  of  possible  results,  in  order  that  he  may 
decide  wisely  before  advising  operative  intervention. 

Another  factor  that  must  be  reckoned  with  is  the  occurrence  of  sup- 
puration in  the  wound  following  a  herniotomy,  because  this  is  the  principal 
cause  of  relapse  of  the  hernia.  We  know  that  some  patients  are  more 
prone  to  infection  than  others,  and  it  is  not  only  advisable,  but  necessary, 
to  determine  this  fact  before  operating.  Sometimes  it  is  well  not  to  operate 
on  such  patients.  It  is  to  be  hoped  that  before  long  it  will  be  possible  to 
forestall  the  occurrence  of  suppuration  by  immunization  done  before 
operating. 

It  is  wrong  and  inadvisable  to  promise  the  patient  a  cure,  because  even 
under  the  most  favorable  circumstances  relapses  have  occurred.  Of  course, 
the  operator  is  expected  to  express  an  opinion  as  to  the  outcome  of  the  case, 
but  this  opinion  should  be  given  only  after  weighing  carefully  all  the  evi- 
dence he  may  have  obtained  by  thorough  examination  and  careful  observa- 
tion. 


PLATE  V. 


Sliding  Hernia  of  the  Sigmoid — laid  open. 
(z-\nthor's  Case.) 


THE    TECHXIC    OF    OPERATIOXS    FOR    HERXIAS  35 

When  strangulation  of  the  hernia  has  occurred,  and  efforts  at  reduc- 
tion made  by  the  patient  himself  (or  by  others)  have  failed,  operation  is 
mdicated,  except  in  most  rare  instances  and  only  under  the  most  unusual 
circumstances.  Then  the  operator  should  resort  to  taxis,  under  anesthesia, 
before  doing  anything  else.  Here,  again,  we  must  not  overlook  the  dan- 
gers which  attend  the  giving  of  an  anesthetic. 

Another  affection  which  is  likely  to  prove  serious  is  that  peculiar 
dyscrasia  known  as  hemophilia — the  bleeder's  disease.  Under  no  circum- 
stances should  the  victim  of  hemophilia  be  operated  on  (strangulation  ex- 
cepted) until  he  has  been  under  treatment  looking  toward  the  relief  of  this 
condition.  Short  and  easy  operations  on  hemophiliacs  have  resulted  fatally. 
While  a  herniotomy  usually  is  not  a  serious  operation,  yet  it  is  apt  to  be  a 
long  one,  which  would  surely  prove  fatal  under  the  conditions  just  re- 
ferred to. 

In  contrast  to  the  "bleeder"  is  the  man  whose  blood  vessels  are  too 
full,  whose  functions  are  too  active.  His  tissues  are  producing  a  large 
amount  of  waste  which  requires  a  correspondingly  increased  activity  on 
the  part  of  the  emunctories  to  remove.  As  a  rule,  such  individuals  have 
been  accustomed  to  an  active  life  and  they  rebel  when  thev  are  compelled 
to  remain  in  bed  for  a  few  weeks  while  recovering  from  the  eft"ects  of  an 
operation.  In  such  cases  the  chances  of  recovery  are  not  as  good  as  they 
are  in  the  less  robust  patient,  the  less  active  individual,  whose  meta- 
bolism has  not  been  over-active,  and  whose  emunctories  have  not  been 
over-taxed.  Before  an  operation  is  undertaken  on  these  robust  persons,, 
or  what  at  one  time  was  called  a  condition  of  plethora,  the  patient  should 
be  dieted  and  purged  freely  for  a  week  or  two,  if  necessary,  so  that  all  his 
functions  may  be  balanced.  It  is  not  often,  however,  that  more  than  four 
or  five  days  of  such  treatment  are  necessary.  Each  individual  is  a  law  unto 
himself,  and  must  be  treated  accordingly. 

(b)  Age.  The  resisting  and  recuperating  powers  vary  at  dift'erent 
periods  in  life.  Experience  has  sho^v■n  that  between  the  ages  of  five  and 
fifteen  major  operations  prove  more  successful  than  at  any  other  period 
of  life.  The  death-rate  is  higher  both  before  and  after  that  time. 
All  wounds  heal  more  rapidly  in  children  than  in  adults.  In  the  former 
regeneration  of  lost  tissue  takes  place  more  quickly  because  all  the  tissues 
are  in  a  state  of  growth,  whereas  in  the  adult,  regeneration  means  the 
awakening  of  a  dormant  process. 

Another  factor  in  favor  of  the  child  is  that  worry  and  anxietv  be- 
cause of  the  impending  operation  do  not  exist.  Children  also  stand  the 
confinement  better ;  they  are  not  so  restless ;  they  are  more  easily  amused 
and  entertained  than  the  adult.  On  the  other  hand,  however,  children 
cannot  endure  pain  without  suffering  markedly  ill  effects.  They  are  very 
prone  to  suffer  profoundly  from  shock.  In  the  case  of  very  young  children 
^nd  infants,  the  dressings,  if  not  protected  properly,  become  soiled  with 
the  discharges  and  suppuration  ensues. 

If  possible,  an  operation  should  not  be  performed  during  the  time  of 
first  dentition,  because  gastro-intestinal  disturbances,  convulsions,  and 
pyrexia  are  apt  to  develop  on  the  slightest  provocation. 


34  THE    TECHNIC    OF    OPERATIONS    FOR    FIERNIAS 

It  cannot  be  denied  that  from  the  time  of  maturity  to  the  termination 
of  life  the  mortality  after  major  operations  for  hernia  increases  with  each 
year  of  life.  The  aged  patient,  however,  who  is  well-preserved  mentally 
and  phvsically  will  withstand  the  operative  cure  of  hernia  without  any 
.material  danger  to  life.-  Of  course,  the  old  are  much  more  likely  to  suc- 
cumb to  the  effects  of  shock,  because  the  vitality  of  their  tissues  has  been 
undermined,  so  that  in  some  instances  the  risk  to  life  is  greater  from  the 
convalescence  than  it  is  from  the  effects  of  the  operation  itself. 

It  is  not  in  the  highest  interests  of  surgical  advancement  to  perform 
an  operation  for  the  cure  of  hernia  on  an  octogenarian  unless  it  is  under- 
taken for  the  purpose  of  relieving  actual  suft'ering  or  to  prolong  life.  Old 
age  of  itself  is  serious  enough  as  a  contra-indication  to  operation,  but 
senile  degeneration  of  the  arteries  and  internal  organs  is  to  be  dreaded  by 
the  surgeon.  Nevertheless,  in  taking  a  retrospective  view,  the  surgeon  can- 
not be  otherwise  than  impressed  by  the  fact  that  the  comfort  of  the  body 
has  been  increased  and  many  lives  saved  by  timely  operations  on  hernias. 

(c)  Sex.  Sex,  on  the  whole,  seems  to  exert  but  little  influence  on 
the  outcome  of  operations  for  the  relief  of  hernia.  This  is  particularly 
true  in  both  the  young  and  old  in  the  comfortable  walks  of  life.  Fem.ales, 
between  the  ages  of  fourteen  and  forty,  usually  stand  the  stress  of  an  oper- 
ation better  than  do  males  between  those  ages.  Women  lead  less  active 
lives ;  they  are  more  patient  and  tolerant  to  house  life ;  they  bear  pain  bet- 
ter; thev  are  more  easily  encouraged,  and  they  are  less  affected  by  hemor- 
rhage, pain,  shock,  vomiting,  etc.,  than  are  men.  The  only  conditions 
that  must  be  considered  in  connection  with  sex  are  those  of  menstruation, 
pregnancy,  lactation,  and  the  climacteric ;  but  as  the  time  for  operations 
for  the  cure  of  hernias  can  in  most  instances  be  chosen,  it  is  unnecessary 
to  operate  during  the  periods  mentioned,  except  when  the  hernia  has  be- 
come strangulated,  when  operation  is  positively  indicated. 

(d)  Habits  and  Disease.  Alcoholism.  Tiiere  are  two  classes  of 
alcoholics  that  demand  the  serious  consideration  of  the  operator,  (i)  the 
confirmed  drunkard,  and  (2)  the  man  wdio  takes  his  "nightcap"  and  his 
"eye-opener"  every  day.  In  both  these  classes  the  operative  mortality  is 
much  higher  than  it  is  in  the  temperate  individual.  Delirium  tremens  com- 
plicates any  operation.  It  is  advisable  to  refuse  all  except  the  most  urgent 
operations  in  heavy  drinkers.  It  takes  more  than  two  weeks  to  eliminate 
alcohol  from  the  system  of  one  who  uses  it  every  day,  and  a  still  longer 
time  to  tone  him  up  before  he  can  be  operated  on  safely. 

Tuberculosis.  Tuberculous  patients  suffer  from  hernia  quite  fre- 
quently. As  a  rule,  it  is  best  not  to  recommend  an  operation  for  the  cure 
of  hernia  in  this  class  of  patients  unless  strangulation  occurs,  when  it  is 
necessary  to  operate  in  order  to  save  life.  Then  a  cure  of  the  hernia  should 
be  eft'ected  at  the  same  time.  If  the  victim  of  the  hernia  is  also  suffering 
from  a  tuberculous  peritonitis  or  a  tuberculous  condition  of  the  hernial 
sac,  an  operation  is  not  only  justifiable,  but  commendable  for  the  treat- 
mcni  of  both  the  tuberculous  disease  and  the  hernia.  Such  operations 
should  be  performed  through  the  hernial  area,  even  at  the  risk  of  infecting 


PLATE  \l. 

Inguinal  and  Ventral  Hernia  with  Suprapubic  Vesical  Fistula. 

(Author's  Case.) 


THE    TECHNIC    OF    OPERATIOXS    FOR    HERXIAS  .  3/ 

the  wound  with  tuberculosis.  In  the  case  of  phthisis  and  tuberculosis  of  the 
joints,  the  operation  for  the  relief  of  hernia  should  be  deferred  until  such 
time  as  the  tubercular  condition  has  been  relieved.  When  the  tuberculosis 
is  confined  to  the  lymph  glands  of  the  neck,  and  a  hernia  also  exists,  the 
glands  should  be  removed  first,  and  the  hernia  not  operated  sooner  than 
three  months  afterward.  Children  who  are  puny  and  poorly-nourished 
should  not  be  operated  on,  even  though  no  positive  evidence  of  tuberculosis 
is  found,  unless  it  is  certain  that  the  hernia  is  materially  interfering  with 
the  child's  well-being.  Of  course,  strangulation  always  is  a  positive  in- 
dication for  operation. 

Syphilis.  This  afi:"ection,  in  an}-  of  its  stages,  is  a  contra-inuication  to 
operation  for  relief  of  hernia,  except  when  strangulation  has  occurred. 
While  it  is  true  that,  as  a  rule,  wounds  of  the  tissues  of  a  syphilitic  heal 
well,  still  there  is  the  exceptional  case  that  does  not  heal  up  promptly,  but 
breaks  down  with  local  manifestations  of  specific  disease. 

Rheumatism,  Gout,  Diabetes  IMellitis  ax^d  other  Coxstitutioxal 
Diseases.  What  is  true  of  tuberculosis  and  sypiiilis  also  applies  to  these 
constitutional  diseases,  especially  during  their  acute  stage.  Operations  on 
diabetics  are  always  to  be  dreaded  because  of  the  uncertainty 'of  the  out- 
come. The  tissues  are  not  in  a  state  that  favors  prompt  and  uncomplicated 
regeneration.  Their  condition  favors  sepsis  and  gangrene.  Therefore  the 
subjects  of  such  diseases  are  not  to  be  operated  on,  except  in  an  emergenc}'. 
Rheumatism  is  not  so  serious  a  complication  as  is  diabetes,  yet  it  is  ad- 
visable to  put  the  patient  under  energetic  medical  treatment  before  attempt- 
ing to  perform  an  operation  for  the  cure  of  the  hernia.  Sometimes  it  is 
necessary  to  operate  on  a  patient  who  is  suffering  from  some  acute  infec- 
tious disease,  but  it  will  be  understood  that  these  are  only  emergency  cases. 
The  judgm&nt  of  the  operator  must  be  the  sole  guide  in  determining  v.  hen 
and  when  not  to  operate. 

Mental  Coxditiox.  The  mental  condition  of  the  patient  always  mate- 
rially affects  the  prognosis  after  a  surgical  operation.  The  patient  who 
has  a  nervous  temperament  always  dreads  an  operation.  He  is  afraid  of 
the  anesthetic;  he  is  afraid  of  the  knife;  and  he  fears  being  hurt.  Often, 
however,  it  is  these  patients  who  display  most  courage  when  there  is  no 
alternative.  They  are  more  calm  and  more  considerate  than  the  average 
patient,  because  they  yield  to  the  inevitable,  knowing  that  it  is  the  only 
way  to  avoid  a  fatal  issue.  The  sullen,  gloomy  and  apathetic  person,  who 
is  filled  with  an  indifference  to  all. that  is  going  on  about  him,  and  who  is 
convinced  that  there  can  be  only  one  outcome,  a  fatal  one,  is  the  most  un- 
favorable to  operate  on.  I  recall  one  case,  that  of  a  man  who  deliberately 
starved  himself  to  death.  He  stood  the  operation  well,  and  the  wound 
healed  nicely,  but  he  absolutely  refused  either  to  drink  or  eat.  He  would 
not  even  retain  food  passed  into  the  stomach  through  a  stomach  tube. 
Although  his  hands  were  tied,  he  succeeded  in  vomiting  up  the  food  by 
persistent  voluntary  efforts.  Nutrient  enemeta  were  expelled  at  once.  Nor- 
mal salt  solution  kept  him  alive  for  two  weeks. 

The  epileptic  and  the  insane  bear  all  operations  well  because  their  men- 


38  THE    TECHXIC    OF    OPERATIONS    FOR    HERNIAS 

tal  condition  in  no  way  interferes  with  the  outcome.  Operations  have  been 
known  to  cure  epilepsy.  Two  such  cures  have  occurred  in  my  own  ex- 
perience. The  statistics  of  operations  on  the  insane  show  a  remarkably 
low  mortality  and  the  surgeon  need  never  hesitate  to  operate  on  this  class 
of  patients,  although  operations  done  for  the  cure  of  hernia  in  the  insane 
are  undertaken  only  in  an  emergency. 

(e)  Preparation.  The  preparation  of  patients  for  operations  is  both 
deliberate  and  emergent,  and  at  the  same  time  local  and  constitutional.  The 
deliberate  preparation  consists  in  allowing  from  one  or  t^vo  to  <:even  or  four- 
teen days,  before  the  patient  is  safely  submitted  to  the  operative  cure  for 
hernia.  As  a  rule,  patients  are  in  the  hospital  twenty-four  hours  before 
an  operation  is  performed.  Those  who  earn  their  living  by  hard  manual 
labor,  who  indulge  excessively  in  athletic  sports,  as  well  as  those  who  lead 
an  automobile  and  club  life,  had  better  be  dieted,  purged  and  generally 
strengthened  by  suitable  tonics  before  being  operated. 

When  a  surgeon  consents  to  shorten  the  time  of  the  preparatory  treat- 
ment, contrary  to  his  usual  and  special  practice  based  on  his  experience 
and  knowledge,  regretable  complications  and  results  may  have  to  be  borne 
with  chagrin,  disappointment  and  sorrow.  In  the  surgical  treatment  of 
hernia,  as  in  that  of  all  other  surgical  conditions,  let  him  not  be  dissuaded 
from  carrvine  out  the  dictates  of  his  conscience. 


CHAPTER  III. 

INSTRUMENTS  USED  IN  HERNIA  OPERATIONS. 

The  instruments  employed  by  the  author  in  performing  operations  for 
the  cure  of  hernia  are  shown  in  illustrations  Nos.  21  and  22. 

Ferguson's    straight    and    curved — large    and    small — angiotrypsic 

forceps  (i,  2,  3). 
Halsted's  mosquito  forceps — straight  and  curved   (5,  6). 
Barrett's  bowel  holder   (7). 
Needle  holder — Ferguson. 
Scissors:     One   Mayo    (dissecting),   and   two   smalls-curved   and 

straight. 
Three   retractors — Byford,    Mayo,   Ferguson. 
Forceps. 

Three  sets  needles — 
Mayo   (bowel)    (i). 
Ferguson,  round  and  cutting  (2). 
Straight  skin  needles  for  horsehair   (3). 
Knives — Two  center-pointed  for  dissecting. 

Two  back-pointed  for  making  incisions,  using  one  for  skin  in- 
cision,  and   the   other   for   incising  the   remaining   structures 
down  to  the  sac. 
Sterile  Instruments  in  Reserve. 

Several  sharp  knives,  3  or  4  scissors,  and  a  razor. 
An  assortment  of  needles. 
Two  dozen  forceps,  small  and  large. 
Catheters — silver,  glass  and  rubber. 
Retractors — sharp  and  blunt. 
Transfusion  needles,  etc. 
In  addition  to  the  above,  the  surgeon  should  have  in  readiness  a  trans- 
fusion apparatus,  Downes'  transformer,  a  thermo-cautery,  and  a  stomach 
tube. 

While  an  expert  surgeon  can  perform  the  operation  for  the  radical 
cure  of  hernia  with  a  very  few  instruments — a  knife,  or  scissors,  tissue 
forceps,  and  a  needle  and  thread — better,  safer  and  cleaner  work  is  done 
by  him  with  a  suitable  supply,  as  here  enumerated. 

The  knives  chosen  should,  above  all  things,  be  sharp.  A  dull-cutting 
scalpel  worries  the  operator  and  unduly  traumatizes  and  also  endangers 
the  tissues.  An  instrument  that  cuts  clean  affords  the  artistic  operator 
an  opportunity  to  sweep  along  so  lightly  that  even  the  small  branches  of 
blood  vessels  are  brought  into  view,  clamped,  and  then  severed,   thereby 


40  INSTRUMENTS    USED    IN    HERNIA   OPERATIONS 

preventing  blood-staining  of  the  tissues.  In  order  to  obtain  the  best  results 
in  operations  for  inguinal  hernia,  it  is  absolutely  essential  to  differentiate 
and  study  the  structures  involved,  and  this  cannot  be  done  accurately  when 
the  tissues  are  stained  with  blood. 

A  large-bellied  scalpel  should  not  be  used  while  a  careful  dissection 
is  being  done  around  the  spermatic  cord.  This  work  demands  a  knife 
whose  point  is  in  its  center,  and  then  the  operator  knows  and  feels  where 
the  cutting  point  is  all  the  time. 

Halsted's  mosquito  forceps  are  sufficient  to  check  the  subcutaneous 
hemorrhage,  but  when  the  superficial  epigastric,  superficial  pudic,  or  super- 
ficial iliac  vessels  are  exposed,  and  have  to  be  severed  (usually  only  the 
superficial  epigastric),  the  Halsted  forceps  are  not  powerful  enough  to 
permanently  check  hemorrhage  without  the  use  of  ligatures,  and  the  fewer 
the  ligatures  the  better,  consequently  it  is  better  to  use  the  author's  angio- 
trypsic  forceps,  the  smaller  size,  straight  and  curved,  which  should  be  left 
holding  the  vessels  until  the  sac  is  ablated,  and  then  removed,  when 
hemostasis  is  complete  and  permanent.  When  we  consider  that  every  liga- 
ture is  a  tax  upon  the  tissues  to  care  for  it,  and  that  it  may  be  an  addi- 
tional source  of  infection,  it  is  an  advance  in  surgical  technic  when  the 
number  of  ligatures  is  limited  to  a  minimum  by  using  efficient  crushing  for- 
ceps, such  as  those  mentioned.  The  author  has  repeatedly  performed  such 
operations  as  herniotomies  and  breast  amputations,  and  trusted  entirely 
to  these  forceps  for  hemostasis,  and  he  has  never  been  disappointed. 

A  larger  vessel  than  is  severed  in  operations  on  hernia,  such  as  all  the 
arteries  and  veins  below  the  upper  third  of  the  leg,  may  be  trusted  to  the 
angiotrypsic  crush  of  the  large  forceps  for  hemostasis.  Vessels  situated 
inside  the  body,  as,  for  example,  the  ovarian  and  uterine  vessels  which 
are  onl}^  secured  in  intermediate  hemorrhage  at  great  risk  to  the  life  of 
the  patient,  are  not  trusted  to  the  angiotrypsic  force  of  the  large  forceps, 
but  this  much  is  gained,  and  that  is.  that  a  very  small-sized  ligature  may 
be  used  efficiently  on  the  vessels  thus  crushed,  say  No.  oo,  and  o,  or  i, 
formalin  chromic  catgut,  instead  of  Xo.  2  or  3,  when  no  such  crushing  is 
done. 

Barrett's  bowel  holder  is  a  useful  instrument  to  drag  out,  hold  and 
replace  bowels,  appendix,  omentum,  ovaries  and  tubes.  It  greatly  facili- 
tates inspection  of  intra-abdominal   contents   Vvuthout  undue  manipulation. 

The  three  retractors  mentioned  (Fig.  22),  Byford's,  Mayo's  and  Fergu- 
son's, have  each  an  especial  application  in  different  hernial  localities. 

The  Byford  retractor  is  suitable  to  raise  up  and  retract  the  abdominal 
wall  after  the  abdomen  is  opened  in  umbilical  or  ventral  hernias,  without 
tearing  the  peritoneum.  This  simple  act  of  raising  the  abdominal  wall 
and  looking  at  the  abdominal  contents  before  passing  the  hand  is  a  useful 
source  of  information  as  to  the  position  of  organs  and  as  to  the  existence 
of  pathologic  conditions. 

Mayo's  retractor  is  the  best  to  protect  the  spermatic  cord  while  oper- 
ating on  inguinal  hernia.  The  cord  is  placed  in  the  broad  space  between 
the  two  blunt  prongs  of  either  end  of  the  retractor,  and  is  held  there  with- 
out fear  of  injury. 


.•4s 


fP^h^//^ 


PLATE  VII. 
Ventral   Hernia   Following   Rupture  of   P.ectus    Muscle    (Thos.    Pickering- 
Pick.) 


INSTRUMENTS    USED    IN    HERNIA    OPERATIONS  43 

The  Ferguson  retractor  has  a  blunt  and  a  sharp  end.  Occasionally 
a  sharp  retractor  is  needed.  The  needles  selected  should  be  both  round 
and  cutting.'  The  author,  of  course,  prefers  his  own  in  all  hernial  opera- 
tions. The  cutting  needles  are  used  only  to  sew  the  skin.  When  the 
bowel  has  to  be  sutured  or  the  appendix  removed,  bowel  needles  of  Mayo's 
kind  had  best  be  employed.  The  be?t  needles  for  inserting  wire  are  those 
devised  by  M.  L.  Harris. 

When  it  is  necessary  to  remove  adherent  or  strangulated  omentum, 
the  electro-thermo-cautery  of  Downes  is  the  most  efficient  instrument  for 
this  work.  At  the  selected  site  for  ablation,  seize  hold  of  the  om.entum 
with  one  or  two  of  Downes'  clamps  and  turn  on  the  current,  which  in  a 
minute  or  so  heats  the  blades  and  cooks  a  strip  across  the  tissues  within  its 
grasp,  and  permanently  forestalls  any  hemorrhage.  The  mass  is  then  cut 
off,  care  being  taken  not  to  cut  outside  of  the  center  of  the  cooked,  ribbon- 
like tract.  Inasmuch  as  the  end  of  the  omental  stump  has  lost  its  vitality 
by  heat,  no  adhesions  can  take  place  to  it. 

In  dealing  with  extensive  omental  and  fibrous  adhesive  bands,  and 
when  it  is  clear  to  the  surgeon  that  the  separation  of  these  adhesions  by 
foi'ce  would  leave  many  or  extensive  raw  surfaces  on  the  parietal  peritoneum 
or  elsewhere,  then  Downes'  electro-thermo-cautery  is  an  instrument  of 
great  value.  It  is  applied  to  the  adhesions,  a  ribbon-like  tract  seared,  and 
in  the  center  of  the  cooked  tissues  the  scissors  is  applied  and  passed  through 
the  stump  or  stumps  proximal  to  the  viscera.  These  are  allowed  to  recede 
and  the  distal  stump  or  stumps  left  to  cling  by  their  adherent  ends,  with- 
out the  danger  of  new  adhesions  forming.  Should,  however,  the  elaborate 
apparatus  of  Downes  be  not  at  hand  or  out  of  order,  and  adhesions,  as 
above  mentioned,  are  encountered,  then  the  angiotrypsic  forceps  come  in 
well ;  clamp  en  masse  in  two  places ;  release  the  forceps ;  tie  in  the  crushed 
grooves,  and  cut  between  them.  Then  bury  the  raw  stumps  between 
omental  or  peritoneal  folds  which  will  prevent  the  formation  of  extensive 
new  adhesions. 

In  hernial  cases  the  omentum  sliould  not  be  amputated  because  it  is 
found  within  the  sac.  If  it  is  not  attached  and  it  appears  normal,  it  should 
be  left  alone.  It  is  singular  but  true  that  it  takes  two  raw  surfaces  to 
create  adhesions.  A  wonderful  example  in  nature  is  to  be  foimd  in  the 
ovary,  whose  surface,  w"here  the  follicle  ruptures,  becomes  raw  once  a 
month  during  menstruation,  and  no  adhesions  follow,  but-  let  infection 
come  on  the  scene  of  operations,  and  cause  traumatism  to  the  surrounding 
structures,  and  the  ovaries  will  soon  become  buried  in  adhesions,  only 
limited  by  the  nature  and  virulence  of  the  special  bacteria  in  the  field. 

The  operator  must  not  forget  how  delicate  the  peritoneum  is,  and 
that  even  handling  bowels  with  gloves  is  liable  to  cause  dangerous  trauma- 
tism and  paresis  of  the  muscular  coats,  with  subsequent  distention,  which 
favors  the  transmission  of  bacteria  from  the  mucous  to  the  peritoneal  mem- 
brane, sufficient  to  agglutina.te  many  coils  of  bowel,  perchance  permanently. 

The  dissecting  scissors,  devised  by  Mayo,  or  Greig-Smxith's,  greatly  fa- 
cilitate the  delicate  task  of  liberating  one  deep  structure  from  another,  with 


44  INSTRUMENTS    USED    IX    HERNIA    OPERATIONS 

the  least  amount  of  danger.  Seizing  the  tissues  with  a  thumb  and  finger 
forceps,  the  operator  makes  gentle  traction.  Then  in  a  clear  field  a  small 
snip  with  the  scissors  makes  an  opening  through  which  the  closed  point 
of  the  scissors  is  inserted,  and  immediately  opened  widely,  wdiich  reveals 
the  structures  sought  for.  In  quick  succession  the  scissors  are  used  as- 
above  mentioned,  until  the  dissection  is  completed,  and  all  the  structures 
in  the  hernial  area  are  differentiated  and  dealt  wnth  secundum  artem.  In 
my  most  delicate  operations  I  am  very  fond  of  using  the  knife  and  gauze, 
but  I  am  sure  that  I  can  work  more  rapidly  and  just  as  safely  with  the 
scissors. 

The  only  operation  for  hernia  that  requires  special  instruments  to 
carry  out  its  original  technic  is  MacEwen's.  He  devised  a  right  and  left 
ligature  carrier,  but  even  in  the  performance  of  his  operation  they  are  no 
longer  required,  because  any  large-sized,  round-pointed  needle,  grasped 
fi.rmly  in  a  suitable  needle  holder,  v."ill  answer  the  purpose  equally  well. 


CHAPTER  IV. 

MATERIALS  ISED  FOR  HERNIAL  OPERATION 
(FERGISON). 

Formalin  chromic  catgut. 

Chromic  catgut — Xo.  00,  o,  i,  and  2. 

Silkworm  gut — small  size. 

Horsehair — large  size. 
The  chromic  or  the  formalin  chrom.ic  catgut  comes  from  the  dealers  in 
alcohol  in  sealed  glass  tubes,  which  are  boiled  for  forty-five  minutes  with- 
out breaking  the  tubes. 

Ligature  and  Suture  Material. — In  all  surgical  operations  extended  use 
is  made  of  various  materials  both  for  ligature  and  suture  purposes.  These 
materials  are  classified  according  to  their  source  into  animal,  vegetable  and 
mineral,  but  for  surgical  purposes  the  classification  is  made  usually  with 
reference  to  the  behavior  of  these  materials  in  the  tissues,  so  that  we  have 
absorbable  and  non-absorbable  materials,  as  follows: 
L     Absorbable. 

1.  Catgut. 

2.  Tendon. 

a.  Kangaroo. 

b.  Deer. 

c.  Ox. 
IL     Non-absorbable. 

1.  AVire. 

a.  Silver. 

b.  Gold. 

c.  Aluminum  bronze. 

2.  Silkworm  gut. 

3.  Horsehair. 

4.  Silk. 

5.  Linen  thread. 

6.  Celluloidin  thread  (  Pagenstecher's). 

/.     ABSORBABLE  SUTURES. 

I.  Catgut. — Catgut  is  obtained  from  the  fibrous  coat  of  the  intestine 
of  sheep.  The  intestines  are  macerated  until  the  serous  and  muscular  coats 
on  the  one  side,  and  the  mucous  coat  on  the  other,  are  easily  scraped  off. 
The  fibrous  coat  remains.  This  is  cut  into  strips  of  different  lengths  and 
thickness.  These  strips  are  then  twisted  spirally  and  are  allowed  to  drv. 
After  they  have  dried  thoroughly  they  are  polished  wdth  pumice  stone  and 


46  MATERIALS    USED    FOR    HERNIAL    OPERATIONS 

rolled  into  coils,  when  the  catgut  is  ready  for  the  market.     This  is  dry  or 
raw  catgut. 

The  ordinary  commercial  catgut  (rawO  is  not  sterile.  It  is  therefore 
unfitted  for  surgical  work.  Besides,  it  is  too  brittle.  When  it  is  j^laced  in 
water  the  catgut  swehs,.  becomes  soft,  slippery  and  elastic,  and  has  a  ten- 
dency to  curve  upon  itself.  But  its  strength  is  not  impaired.  If  catgut  i* 
boiled  in  water  without  having  been  put  through  a  special  process,  it  is 
cooked  and  rendered  useless  for  surgical  purposes.  In  order  to  be  used 
for  ligatures  and  suture  material,  the  catgut  must  be  made  aseptic  and 
pliable. 

Catgut  is  used  in  two  forms,  either  as  aseptic  or  antiseptic.  The  first 
form  is  simply  rendered  sterile,  while  the  second  is  permeated  with  some 
antiseptic  agent,  such'  as  iodine,  carbolic  acid,  chromic  acid,  etc. 

The  aseptic  catgut  is  used  either  dry  or  moist.  The  dry  form  is  soft- 
ened in  the  tissues,  swells  and  acts  as  a  culture  medium  for  bacteria.  Be- 
cause of  this  fact  the  dry  form  of  catgut  must  not  be  used  to  suture  the 
skin  or  mucous  membranes.  The  germs  that  are  not  removed  from  the 
skin  find  this  aseptic  catgut  a  more  suitable  pabulum  on  which  to  multiply 
than  the  wound  secretion.  This  gives  rise  to  stitch  abscesses.  Aseptic 
catgut  has  no  germicidal  power,  while  the  blood  serum  has  a  very  marked 
action  in  that  direction,  as  have  also  the  living  tissues.  x\septic  catgut  is 
more  suitable  for  tying  blood  vessels  that  are  situated  deeply  in  the  tissues 
where  bacteria  are  not  found  normally.  If,  however,  a  large  amount  of 
catgut  is  placed  deeply  in  these  tissues,  infection  is  quite  likely  to  occur. 
Inasmuch  as  sterile  or  aseptic  catgut  has  no  advantage  over  antiseptic  cat- 
gut, and  has  many  disadvantages,  it  has  practically  been  discarded,  especial- 
ly in  operations  for  the  cure  of  hernia. 

There  is  another  reason  why  aseptic  catgut  cannot  be  used  in  hernia 
operations,  and  that  is  because  it  is  absorbed  in  too  short  a  time,  before 
granulation  tissue  has  become  thoroughly  organized,  wdien  the  structures 
yield  readily  to  intra-abdominal  pressure  and  relapse  of  the  hernia  is  fa- 
vored. 

Antiseptic  catgut  may  be  prepared  in  a  manner  that  either  will  hasten 
or  retard  its  absorption.  Carbolized  catgut  remains  antiseptic  in  the  tis- 
sues for  only  a  short  time.  As  soon  as  the  carbolic  acid  is  eliminated  from 
the  catgut,  the  latter  is  converted  into  an  aseptic  catgut,  and  possesses  the 
same  properties  and  disadvantages  as  does  aseptic  catgut.  The  same  is 
true  of  catgut  that  has  been  sterilized  with  bichloride  of  mercury  and  cer- 
tain other  agents. 

The  best  catgut  is  that  which  has  been  prepared  by  the  formalin  method. 
It  becomes  very  hard  and  can  be  boiled  safely  without  being  cooked.  This 
is  also  true  of  chromic  catgut.  Catgut  that  has  been  treated  with  formalin 
and  with  chromic  acid,  a  variety  that  I  have  been  using  for  some  years, 
does  not  swell  in  the  tissues  as  does  the  plain  sterile  catgut,  and  the  action 
of  the  phagocytes  on  it  is  from  without  inward,  so  that  the  catgut  remains 
antiseptic  while  a  shred  of  it  is  left.  This  catgut  is  not  absorbed  rapidly,, 
and  it  is  therefore  very  suitable  for  use  in  hernia  operations.     Even  the 


PLATE  Mil. 

Posterior  Hernia  through  Duodeno- jejunal  Fossa. 
Transactions  of  the  Society  (Pathological)   of  London,  \'ol.  II. 
I.  Sac  of  the  hernia  situated  behind  the  folds  of  the  meso-colon.    2.  The 
lower  portion  of  the  ileum,  passing  out  of  the  hernial  sac.     3.  The  caput 
coli.     4.  The  displaced  portion  of  the  transverse  colon. 


MATERIALS    USED    FOR    HERNIAL    OPERATIONS  49 

finest  strand  of  formalin-chromic  catgut  does  not  become  absorbed  before 
the  expiration  of  twelve  or  fourteen  days.  No.  6  catgut  is  not  absorbed 
until  the  expiration  of  six  months.  Nos.  i  and  2  are  absorbed  inside  of 
three  or  four  weeks,  just  the  time  required  in  hernia  work.  Chromic  cat- 
gut, because  of  its  greater  strength,  can  be  used  in  smaller  sizes.  I  prefer 
to  use  sizes  No.  00,  o,  i  and  2. 

Iodine  catgut  and  pyoktannin  catgut  are  also  used,  in  fact  preferred, 
by  some  operators,  but  this  catgut,  like  that  prepared  according  to  the  cumol 
and  abolene  method,  becomes  aseptic  when  the  agent  used  is  abstracted 
from  the  catgut  by  the  tissue  fluids.  For  some  purposes  the  iodine  and 
pyoktannin  catguts  are  very  useful  because  of  the  color. 

The  fine  catgut  that  is  prepared  by  the  formalin-chromic  acid  process 
may  be  made  so  antiseptic  that  it  can  be  used  for  suturing  the  skin  and 
mucous  membranes  with  impunity,  because  before  absorption  of  this  very 
hard  material  can  take  place  the  time  for  its  removal  has  passed. 

There  is  no  operation  for  hernia  of  any  kind  in  \vhich  catgut  cannot 
be  used  without  danger  of  infection,  but  it  is  not  the  most  suitable  material 
to  use  for  coapting  the  skin  wound. 

2.  Tendons.- — The  tendons  that  are  used  in  surgical  work  are  derived 
from  the  kangaroo,  the  deer  and  the  ox.  Tendon  has  one  vei?y  great  ad- 
vantage that  is  not  possessed  by  catgut — viz.,  when  it  is  removed  from 
the  body  it  is  sterile.  If,  however,  the  tendons  are  not  properly  cared  for 
immediately  after  their  removal  from  the  body,  or  if  they  are  not  removed 
from  the  body  before  decomposition  takes  place,  they  may  be  found  loaded 
with  germs. 

Because  of  these  accidents  which  may  render  tendon  septic,  it  is  ad- 
visable to  asepticize  it  by  the  use  of  chemicals,  such  as  alcohol,  carbolic 
acid,  corrosive  sublimate,  etc. 

Tendon  has  another  advantage  over  catgut,  and  a  very  valuable  one  at 
that,  in  that  it  is  not  readily  absorbed,  so  that  it  does  not  require  hardening 
or  any  special  preparation  with  formalin,  or  some  other  substance ;  nor 
does  it  require  boiling.  The  natural  asepticity  of  tendon,  its  durability  in 
the  tissues,  and  the  readiness  with  which  it  can  be  split  up  into  small  and 
large  threads,  makes  it  a  very  suitable  material  for  suturing  together  the 
deep  structures  in  hernia  operations.  To  H.  O.  ]\Iarcy,  of  Boston,  may  be 
given  the  credit  of  championing  this  material. 

II.     NON-ABSORBABLE  SUTURES.  - 

I.  Wire. — Wire  sutures  possess  some  advantages  that  make  them 
very  useful  for  certain  kinds  of  work,  but,  all  things  considered,  they  do 
not  take  the  place  of  either  catgut  or  tendon.  Wire  is  easily  made  aseptic. 
It  is  pliable,  especially  the  silver  wire,  and  it  is  not  affected  by  the  tissue 
fluids.  Aluminum  bronze  wire  is  better  than  silver  wire,  because  it  pos- 
sesses greater  tensile  strength.  It  does  not  break  or  kink  as  readily  as 
does  silver.    The  only  objection  to  gold  wire  is  its  cost. 

Silver  wire  v/as  at  one  time  used  very  freely  as  a  buried  suture.  It 
does  not  cause  any  irritation  of  the  tissues  and  in  the  passive  tissues  of  the 
body,  such  as  bone,  it  remains  for  an  indefinite  period  without  causing  anv 


50  MATERIALS    USED    FOR    HERNIAL    OPERATIONS 

disturbance  whatever.  It  is  still  used  extensively  for  wiring  bones.  Ex- 
perience has  shown  that  silver  wire  when  used  in  hernia  operations  will 
work  its  way  out  to  beneath  the  skin,  necessitating  its  removal.  This  does 
not  occur  until  months  or  sometimes  years  after  it  has  been  placed  in  the 
tissues,  but  this  property  makes  the  use  of  the  wire  decidedly  objectionable. 
Many  cases  have  been  reported  where  the  wire  was  removed  as  long  as 
fifteen  years  after  its  insertion.  If  wire  is  used  at  all  in  operations  for  the 
cure  of  hernia,  it  should  be  according  to  the  method  described  by  M.  L. 
Harris.  This  method  makes  it  possible  to  remove  the  wire  after  it  has 
fulfilled  the  purpose  for  which  it  was  intended. 

2.  Silkivorm  Gut. — This  is  obtained  from  the  silkworm  in  the  larva 
stage.  It  is  small  and  strong,  smooth  and  hard.  It  is  sufficiently  pliable 
to  stand  the  tying.  It  does  not  harbor  germs  in  its  interstices  to  any 
marked  degree,  and  does  not  readily  carry  germs  to  the  deeper  structures. 
It  is  easily  sterilized,  and  withstands  repeated  boilings.  It  must  not  be 
used  as  a  buried  suture,  however,  experience  having  shown  that  it  causes 
irritation  not  unlike  that  produced  by  wire.  This  is  followed  by  suppura- 
tion, necessitating  the  removal  of  the  material.  Silkworm  gut  is  very  suit- 
able for  suturing  skin  wounds.  If  found  necessary  for  suturing  the  deeper 
structures  it  should  be  used  according  to  the  method  recommended  by 
Charles  A.  Davison,  so  that  it  can  be  removed  after  the  tissues  have  united. 
Although  silkworm  gut  is  not  elastic,  it  accommodates  itself  very  nicely  to 
the  shape  and  form  of  the  tissues.  It  is  sterilized  by  steam  or  boiling  water 
for  half  an  hour,  and  is  then  preserved  in  suitable  vessels. 

Lockwood  doubts  its  ready  sterilization  by  one  boiling",  having  found 
it  septic  in  two  cases  out  of  thirty-seven  instances  after  it  had  been  boiled 
for  twenty  minutes.  If  silkworm  gut  is  boiled  with  soda  it  is  softened, 
and  its  tensile  strength  is  lessened.  Inasmuch  as  Lockwood's  observation 
is  no  doubt  true,  it  is  better  to  sterilize  silkworm  gut  by  the  fractional 
method.  Whenever  hernial  wounds  have  to  be  drained,  several  strands  of 
sterilized  silkworm  gut  can  be  used  advantageously. 

3.  Horsehair.  This  material  is  obtained  from  the  manes  and  tails 
of  horses.  It  is  smooth,  elastic,  and  resilient.  It  is  easily  rendered  aseptic 
and  is  only  slightly  absorbable.  It  is  very  suitable  material  for  coapting  skin 
wounds.  It  can  be  rendered  aseptic  without  boiling.  Boiling  destroys  the 
elasticity  of  the  hair  more  or  less,  and  makes  it  very  brittle.  In  order  to 
render  it  absolutely  aseptic,  it  ought  to  be  sterilized  by  the  fractional  method, 
but  this  process  destroys  the  hair  and  unfits  it  for  use  as  a  suture  material. 
Hair  is  the  only  material  that  nature  allows  to  pass  through  the  skin  with 
impunity.  This  is  its  normal  habitat,  and  consequently  the  hair  does  not 
cause  any  irritation.  That  is  probably  the  rcaiuu  why  hair,  though  not 
absolutely  aseptic,  can  be  used  very  freely  as  a  superficial  suture  without 
causing  any  infection.  It  is  not  suitable  for  buried  sutures.  Another 
point  in  its  favor  is  that  even  when  it  is  tied  too  tightly,  it  accommodates 
kself  readily  to  the  wound  by  stretching  and  thus  does  not  cause  the  local 
necrosis  which  occurs  so  often  when  silkworm  gut,  wire  or  other  suture 
material  is  used. 


.MATERIALS    USED    FOR    HERNIAL    OPERATIONS  51 

Horsehair  is  prepared  by  first  immersing  it  in  a  four  per  cent,  boiling- 
soda  solution,  which  removes  grease  and  other  foreign  substances.  After 
being  brushed  and  washed  it  is  boiled  for  fifteen  minutes,  and  is  then  kept 
in  a  weak  solution  of  carbolic  acid,  1-20.  or  bichloride,  i-iooo.  Horsehair 
is  also  prepared  by  putting  it  through  the  same  process  as  that  used  for 
disinfecting  the  hands  and  then  preserving  it  in  alcohol. 

4.  Silk.  Silk  is  employed  in  the  form  of  twisted  or  braided  silk. 
The  varieties  of  twisted  silk  used  are  ordinary  surgical  silk,  cable  twisted 
silk,  and  saddler's  silk.  Surgical  silk  is  used  in  sizes  from  No.  00  to  No. 
14,  and  in  color  is  either  white  or  iron  dyed,  the  advantage  of  the  latter 
being  its  ^asy  detection  when  deeply  embedded  in  the  tissues. 

Cable  silk,  or  Tait's  silk,  is  more  easily  manipulated,  is  of  firmer  texture, 
and  is  less  liable  to  slip  when  knotted  than  ordinary  silk  on  account  of  the 
animal  matter  left  in  its  meshes  by  the  worm  during  the  spinning  process. 

Saddler's  silk,  except  for  its  cheapness,  possesses  absolutely  no  ad- 
vantages over  surgical  or  cable  silk. 

Braided  silk  is  prepared  by  braiding  together  several  strands  of  twisted 
silk.     It  is  very  strong  and  has  no  tendency  to  kink. 

Silk  is  very  strong  and  pliable,  and  the  smaller  sizes  of  it  are  disinte- 
grated by  phagocytic  action.  The  small  particles  are  carried  to  different 
parts  of  the  surrounding  tissues,  where  they  become  encysted.  Applied  to 
the  more  passive  structures,  such  as  tendons  and  fascia,  silk  nearly  always 
becomes  encysted.  The  objection  to  it  as  a  buried  suture  is  that  it  is  a 
foreign  body,  hence  predisposes  to  suppuration. 

Of  all  the  suture  materials  used,  silk  follows  the  needle  with  the  least 
amount  of  traumatism ;  but  it  is  non-absorbable,  and  is  likely  to  carry 
bacteria  in  its  w^ake.  In  my  opinion,  it  should  not  be  used  as  a  buried 
suture  in  any  hernia  operation.  If  its  use  is  imperative  from  lack  of  choice, 
the  smallest  size  possible  should  be  selected.  Clinical  surgery  is  replete 
with  so  many  instances  of  secondary  suppuration  following  the  use  of  buried 
silk  in  hernia  operations  that  it  is  practically  discarded,  although  a  few" 
noted  surgeons  still  use  it. 

5.  Linen  Thread. — Linen  thread  is  a  substitute  for  silk,  but  should  be 
used  only  in  an  emergencv.  The  same  objections  pertain  to  it  as  to  silk, 
even  more  so,  because  it  is  coarser  and  more  easily  absorbs  germs  in  its 
meshes.  It  also  breaks  more  easily.  If  linen  thread  must  be  used  for 
ligature  material,  the  smallest  size  possible  should  be  chosen. 

6.  Celluloid  Thread. — In  the  absence  of  catgut  and  tendon  the  celluloid 
thread,  or  Pagenstecher's  thread,  mav  be  ased.  It  has  the  advantage  over 
silk  and  linen  in  that  it  is  coated  with  celluloid  and  consequently  is  less 
absorbent.  It  is  impermeable  to  fluids.  Like  silk,  it  is  easily  manipulated, 
and  is  readily  sterilized.  It  is  strong;er  than  silk  and  also  is  more  durable. 
While  it  will  stand  a  few  boilings,_  frequent  repetitions  of  the  boiling  will 
disintegrate  the  thread.  It  should  not  be  used  in  operations  for  the  radical 
cure  of  hernia.  Only  catgut  or  tendon  should  be  employed.  The  celluloidin 
thread  is  used  to  some  extent  in  intestmal  sureerv. 


CHAPTER  V. 

THE  CHICAGO  HOSPITAL  OPERATING  ROOM  TECHNIC 

(FERGUSON). 

Head  Nurse. — The  head  nurse  is  the  surgical  nurse.  She  has  charge 
of  the  operating  room,  the  daily  work  and  instruction  of  the  three  nurses 
under  her,  and  during  operations  handles  the  instruments,  and  must  wear 
gloves.  She  prohibits  visitors  running  in  and  out;  and  no  lounging, 
coughing,  laughing,  talking,  whistling  or  singing  at  any  time  is  allowed  in 
aseptic  quarters.  The  head  nurse  is  responsible  also  for  the  personal  toilet 
of  the  nurses. 

Second  Nurse,  Daily  Work. — Order  drugs,  muslin,  gauze  and  cotton. 
Keep  front  operating  room  in  order.  Keep  clean  labels  on  bottles.  Work 
quietly. 

Before  Operation. — Scrub  up ;  assemble  materials ;  have  in  place  sur- 
geon's gowns,  visitors'  gowns,  rubber  goods,  caps  and  brushes.  Help  set 
operating  room,  and  keep  surgically  clean  by  covering  all  breaks  in  the 
antiseptic  chain. 

During  Operation. — Help  fill  basins,  solutions  and  percolators.  Keep 
solutions  proper  temperature.     Help  scrub  patient.     Keep  clean. 

After  Operation. — Ventilate  rooms.  Clean  rubber  goods,  brushes,  and 
help  with  instruments. 

Third  Nurse,  Daily  Work. — Keep  back  operating  room  in  order. 
Sterilizers  and  sterilized.  Fill  boric  and  carbolic  buckets.  Boil  soap, 
brushes,  and  nail  files. 

Before  0 peration.-^Scruh  up.  Set  anesthetizer's  tray ;  help  with  oper- 
ating room.     Keep  clean. 

During  Operation. — Help  fill  basins;  place  sponges.  Take  binder  oft. 
Help  with  stirrups. 

After  Operation. — Pick  up  soiled  linen  and  help  with  basins. 

Fourth  Nurse,  Daily  Work. — Order  soap  (laundry  and  toilet),  candles, 
soda,  sapolio,  razors,  matches,  toothpicks.  Keep  preparatory  room  in  order, 
and  sinks  clean.  Sterilizers  and  surgeon's  bathroom,  dressing  chute,  sup- 
ply closet,  cart,  and  wind  clock.     Keep  quiet. 

Before  Operation. — Scrub  up.  Wash  furniture  with  5  per  cent,  car- 
bolic. Tie  door-knobs  with  gauze  wet  with  bichloride.  Fill  glasses  with 
green  soap  (sterile),  and  put  in  place!  Help  set  operating  room.  Keep 
clean ;    help  to  gown  operator  and  assistants  aseptically. 

During  Operation. — Wear  gloves.  Sponge  when  needed.  When  not 
sponging,  keep  faces  clean.  Help  fill  solutions.  Count  sponges  carefully 
and  count  again  when  finished.     Disgown  operator. 


CHICAGO    HOSPITAL    OPERATING    ROOM    TECH  NIC  53 

After  Operation. — Assist  in  putting'  on  dressings,  changing  gown,  get- 
ting in  cart,  blankets  over  patients.  Go  to  room  with  patient,  taking  towels, 
wet  gown  and  record.  See  that  porter  conies  to  mop.  Pick  up  dressings, 
and  clean  basins.  After  each  operation  all  basins  are  sterilized  by  live 
steam  for  two  hours  under  high  pressure,  and  when  used  in  septic  cases 
I  in  20  carbolic  acid  solution  as  well,  and  kept  in  canvas  bags. 

CARE  OF  OPERATING  ROOMS. 

Por^^r.— Cleans  floors  after  each  operation.  Every  morning  before 
operations  the  floors  and  furniture  are  mopped  \\ith  carbolic  acid  (5  per 
cent.).  The  walls  are  washed  with  soap  and  water  and  then  with  carbolic 
acid  solution  (5  per  cent.)  or  bichloride  solution  ( i  to  500),  at  least  once  a 
week.  After  a  pus  case  the  operating  room  is  immediately  fumigated  with 
formaldehyde  for  twelve  to  twenty-four  hours.  Once  in  three  months  the 
walls  are  repainted.     All  the  windows  are  closely  screened  and  kept  clean. 

After  pus  cases  instruments  are  boiled  twenty  minutes,  allowed  to 
stand  twenty-four  hours,  and  boiled  again.  This  is  done  three  times,  allow- 
ing twenty-four  hours'  interval  each  time.  A  shorter  method  is  to  scrub 
the  instruments  in  lysol  solution  until  they  are  thoroughly  freed  from  pus, 
blood,  etc.,  then  submerged  in  95  per  cent,  carbolic  acid  for  five  minutes, 
and  transferred  directly  to  the  2  per  cent,  soda  solution,  in  which  they  are 
boiled  for  twenty  minutes.  The  instruments  are  then  finally  dried,  polished 
and  returned  to  the  instrument  case. 

For  Sterilising  Horsehair. — Ten  minutes  in  ether;  10  minutes  in  alco- 
hol; 10  minutes  in  bichloride.  Then  allow  to  stand  in  alcohol.  Boil  silk- 
worm gut  and  wire  with  instruments,  after  being  autoclaved  or  sterilized 
fractionally  by  boiling  in  sealed  glass  tubes  (chromic,  Nos.  00,  o,  i,  2,  from 
dealers). 

All  catgut  is  to  be  boiled  forty-five  minutes  before  using.  (This  is 
chromic  or  formalin  chromic  catgut  that  is  bought  in  sealed  glass  tubes.) 

Iodoform  Emulsion. — Ten  parts  sterile  glycerine,  1  part  sterile  iodo- 
form.    (Supply  always  on  hand.) 

Iodoform  Gauze. — Glycerine,  sterilized,  oz.  2 ;  iodoform  powder,  oz.  2 ; 
alcohol,  oz.  2 ;  green  soap  solution,  oz.  2. 

Things  necessary  for  making :  Two  sterile  basins,  i  for  hand  solu- 
tions, T  for  iodoform  powder ;  i  sterile  medicine  glass ;  i  sterile  sheet ;  ster- 
ile plain  gauze.  When  finished,  sterilize  twenty  minutes  at  fifteen  pounds 
pressure,  then  put  in  sterile  jars. 

Normal  salt  for  filling  flasks  for  transfusion:  Dissolve  8  tablets  (in 
one  bottle)  in  small  amount  of  water;  filter  through  sterile  cotton  into 
sterile  flask,  which  holds  one  quart ;  sterilize  in  autoclave  at  high  pres- 
sure (fifteen  pounds),  for  one  hour.     (1,000  cc.  flasks  always  ready.) 

Normal  salt  in  hulk  :  Dissolve  8  ta-blets  to  each  mark  on  normal  salt 
bottle  ;  filter  through  sterile  cotton,  after  boiling,  into  sterile  bottle.  Add 
enough  sterile  water  to  fill  bottle.  Sterilize  in  autoclave  at  high  pressure 
for  one  hour. 

Carbolic,  5  per  cent,  in  hulk:  Take  12  ounces  of  95  per  cent,  carbolic. 


54  CHICAGO    HOSPITAL    OPERATIXG    ROOM    TECHXIC 

add  2  ounces  of  95  per  cent,  alcohol,  boil  with  small  amount  of  water.  Add 
enough  sterile  water  to  make  two  gallons. 

Carbolic^  P5  per  cent.,  in  bulk  :  Add  5  per  cent,  of  water  to  carbolic 
crystals,  take  cork  out  of  can,  place  can  in  pail  of  water  and  boil  until 
liquid,  or  liquefy  the  crystals  first  in  a  water-bath  and  add  the  5  per  cent, 
water  afterwards. 

One  to  500  bicJiloride,  in  bulk  :  Dissolve  600  grains  bichloride  powder 
in  a  small  amount  of  water,  add  to  make  4}^  gallons.  Add  enough  picric 
acid  to  give  a  distinct  color. 

Harrington's  Solution:  Commercial  alcohol  (94  per  cent.),  640  c.  c. ; 
hydrochloric  acid,  60  c.  c. ;  water,  300  c.  c. ;  corrosive  sublimate,  0.8  grams. 

Saturated  Solution  of  Boric  Acid  (in  bulk)  :  Place  boric  crystals  in 
gauze,  then  in  pail  or  jar.  Pour  in  hot  water.  Allow  to  stand  and  dis- 
solve as  much  as  possible,  keeping  more  crystals  in  pail  than  possible  to 
dissolve.     Strain  and  boil  before  filling  percolators. 

Green  Soap  Solution  {in  hulk)  :  Take  34  ounce  of  hard  green  soap 
to  one-half  gallon  of  water  and  boil. 

Sterilised  Gauze:  Measure  five  yard  lengths  of  18  pieces  at  a  time; 
loosely  roll  and  place  in  sterile  sheet,  and  sterilize  in  autoclave  at  high  pres- 
sure (fifteen  pounds)  for  two  hours.  Then  cut  for  dressings  or  for  sur- 
gical jars,  after  which  each  must  be  sterilized  in  autoclave  for  one  hour. 
Sponges  and  drawn  gauze  are  sterilized  by  the  same  process  as  above.  All 
the  sheets  are  loosely  rolled  and  autoclaved  for  at  least  one  hour.  The 
same  sterilization  is  done  with  glass  jars  loosely  filled  with  cat  gauze. 

Sponges  are  kept  in  5  per  cent,  carbolic  before  using,  are  waslied  by 
gloved  nurse  in  sterile  water,  and  then  boiled  tw^enty  minutes.  All  articles, 
glass  parts,  catheters,  rubber  tissue,  etc.,  kept  in  glass  jars  in  solution  of 
saturated  boric  acid,  except  silk  (95  per  cent,  alcohol),  and  again  boiled 
before  using. 

Brushes,  when  gotten  out  of  sterilized  jars,  are  kept  in  bichloride,  as 
are  also  the  catgut  tubes. 

Floor  laparotomy  sets  contain  one  large  piece  and  two  small  pieces  af 
combination  dressing,  inclosed  in  a  cotton  cloth  cover. 

Operating  room  laparotomy  set  in  cloth  cover  contains  15  safety  pins 
in  a  string,  laparotomy  binder,  perineal  straps,  2  large  pieces  of  combina- 
tion dressing  (cotton  and  gauze),  sterile  gauze  packages,  one  dozen  in 
each,  supplied  separately. 

Floor  dressing  set  contains  one  large  piece  of  combination  cut  into 
three  pieces.     Gauze  in  separate  packages. 

Operating  room  set  contains  in  cover  one  binder,  two  pieces  (^f  com- 
bination, 15  safety  pins. 

All  specimens  must  be  plainh  marked  with  patient's  name,  floor,  niui'!- 
ber  of  room,  and  doctor's  name.  Put  in  4  per  cent,  formalin,  sealed,  and 
taken  to  laboratory  without  delay.  Head  surgical  nurse  responsible  for 
specimens. 

Each  full  set  of  basi)is  in  a  sterile  bag  contains:  Hand  solution  basins, 
7  for  racks,  4  smaller,  i  specimen,  2  small  for  instrument  table,  I  pitcher;  15 
pieces. 


Pericardial  Diaphragmatic  Hernia  of  the  Omentum. 
Transactions  of  the  Pathological  Society  of  London.     (M.  Miirrant  Baker.) 
A.  Pericardium  laid  open  and  reflected  so  as  to  expose  the  omentum, 
which  covers  the  front  and  sides  of  the  heart.     B.  The  diaphragmi.     C.  The 
stomach. 


CHICAGO    HOSPITAL    OPERATING    ROOM    TECHNIC  57 

Odds  and  ends  in  a  sterile  hag:  Four  pitchers;  2  long  basins,  one 
for  alcohol,  for  needles,  knives,  etc.,  and  one  for  carbolic,  for  sterilizing 
cutting  instruments,  needles,  etc. ;  2  small  round  basins ;  2  hand  solution 
basins;  i  pus  basin;  i  small  basin,  for  Harrington's  solution  for  hands; 
14  pieces. 

SERVICE    STAFF — NIGHT    SUPERINTENDENT. 

Has  charge  of  office ;  answers  telephone,  bell  calls,  makes  three  rounds 
of  all  the  floors ;  posts  operations  for  following  day ;  instructs  night  nurse 
in  operating  room ;  reports  births  and  deaths  to  Superintendent  at  once ; 
looks  after  the  comfort  of  relatives  and  friends ;  assembles  emergency 
supplies,  and  takes  charge  of  the  operating  room  when  emergency  cases 
are  admitted  for  operation.  While  in  the  operating  room,  the  head  nurse 
on  the  second  floor  takes  charge  of  the  office.  The  entire  hospital  is  kept  in 
readiness  for  any  kind  of  professional  work  by  night  as  well  as  by  day. 

NIGHT  SURGICAL  NURSE. 

Stays  in  preparation  room  between  the  two  operating  rooms  all  night. 
In  emergency  work  puts  the  room  in  order,  boils  instruments,  prepares 
solutions,  etc.,  etc. ;  in  brief,  assumes  the  functions  of  the  day  surgical 
nurses.  Her  chief  function  outside  of  the  above  is  to  prepare  gauze  and 
sterilize  in  autoclave  or  boil  (fractional  method)  all  materials  used  in  opera- 
tions. Usually  both  methods  of  sterilization  are  simultaneously  carried  out. 
She  also  assists  the  internes  when  night  dressings  of  wounds  are  imperative, 
or  transfusions  are  made. 

Operator  and  assistants  appear  in  sterile  clothing  from  cap  to  shoes. 

Fifteen  Minute  Method. — Scrub  up  with  sterile  brushes  and  sterile 
.-soap  for  ten  minutes,  changing  nail  brushes  two  or  three  times,  and  using 
running  sterile  water.  The  nail  files  are  sterile  and  must  be  used  before  the 
final  scrub.  The  hands  are  then  scrubbed  in  alcohol,  70  per  cent.,  and 
lysol  (5i  to  §j),  or  bichloride  solution  (i  to  2,000)  consuming  five  minutes 
with  the  antiseptics.  Then  sterile  rubber  gloves  are  filled  with  lysol  solu- 
tion and  pulled  on.  This  antiseptic  permeates  the  skin  of  the  hands  while 
thus  gloved,  acting  as  a  continuous  antiseptic,  and  should  a  glove  be  injured 
there  is  no  danger  of  infecting  the  wound  from  this  source.  Instead  of 
the  alcohol,  lysol  or  bichloride,  the  Harrington  solution  is  preferable. 

Ten  Minute  Method. —  (a)  Scrub  up  with  soap  and  water  for  eight 
minutes ;  (b)  scrub  hands  in  Harrington's  solution  for  two  minutes.  Ready 
for  operating  with  oi'  without  gloves. 

Four  Minute  Method. — Two  minutes  with  ether,  using  (a)  brush  for 
one  minute;  (b)  gauze  for  one  mmute.  Two  minutes  with  Harrington's 
solution. 

In  five  minutes  the  surgeon  can  render  his  hands  and  operative  field 
practically  aseptic :  Ether  oit  hands,  one  minute ;  ether  on  hands  and  field 
of  operation  simultaneously  for  two  minutes,  and  then  Harrington's  solution 
simultaneously  for  two  minutes. 

Rubber  gloves  are  used  by  the  operator  (Ferguson)  in  70  per  cent, 
-of  cases ;  by  his  assistant  internes  and  nurses  in  all  cases  in  which  contact 
infection  is  possible. 


CHAPTER  VI. 

INDICATIONS  FOR  OPERATION. 

OBLiaUE  INGUINAL  HERNIA. 

Any  person  afflicted  with  an  inguinal  hernia  is  a  surgical  case,  but  the 
mere  presence  of  such  a  hernia  does  not  invariably  and  indiscriminately 
demand  an  operation.  The  general  health  of  the  patient,  his  age,  occupa- 
tion, obesity  and  various  other  conditions  must  be  taken  into  considera- 
tion. 

General  Health. — The  presence  of  a  hernia  sometimes  detrimentally 
affects  the  general  health  of  a  child  or  of  a  youth.  Because  of  fear  of 
mjury,  chafing  of  the  truss,  pain  or  strangulation  of  the  rupture,  the  af- 
flicted one  is  not  able  to  participate  fully  in  the  exercises,  plays  and  out-of- 
door  sports  so  essential  to  good  health  and  natural  development.  I  have 
frequently  observed  a  delicate  boy,  handicapped  in  almost  every  muscular 
movement,  undergo  a  remarkable  change  in  health  and  habits  soon  after 
his  rupture  was  cured,  becoming  a  ruddy,  romping,  muscular  fellow. 

Age. — In  infants  an  operation  is  indicated:  (a)  When  the  hernia  is 
very  large  (colossal)  and  constantly  increasing  in  size.  If  an  early  opera- 
tion is  not  performed  the  abdominal  cavity  is  liable,  in  time,  to  become  too 
small  to  hold  the  hernial  contents  with  comfort,  (b)  If  strangulation  oc- 
curs, (c)  Should  the  hernia  be  a  source  of  continual  annoyance,  and  not 
readily  controlled  by  pressure,  it  is  not  in  the  best  interests  of  the  hernial 
area,  nor  beneficial  to  the  general  healtii  and  development  of  the  child,  to 
defer  operation  until  he  begins  to  walk.  Mechanical  appliances  have  a 
wide  range  of  usefulness  from  birth  imtil  the  time  the  child  begins  to  walk. 
A  large  percentage  of  cases  are  spontaneously  cured  with  gentle  support 
to  the  hernial  protrusion  during  this  age. 

Weak  and  undeveloped  children  bear  the  operation  of  radical  cure  bad- 
ly. When  surgical  interference  is  acceded  to,  precautions  should  be  taken 
against  contagious  and  infectious  diseases.  Children  reduced  in  flesh  by 
diarrhea  or  other  diseases  should  be  attacked  cautiously  with  the  knife. 
When  a  child  begins  to  run  about  and  still  has  a  congenital  or  an  acquired 
hernia,  as  a  rule  I  advise  an  operation.  There  is  no  valid  reason  for  delay- 
ing the  operation  until  the  school  age  is  reached.  Damage  to  the  testicle 
may  be  initiated  by  procrastination.  In  consideration  of  the  minimum  risk 
to  life,  and  the  maximum  good  results  ensured  by  the  radical  cure  for 
inguinal  hernia,  there  is  no  age  at  which  it  cannot  be  safely  offered  as  a 
remedy. 

All  hernias  of  the  inguinal  variety  in  both  sexes  between  two  and  forty 
or  fifty  years  of  age  should  be  cured  by  operation,  if  circumstances  and 


IXDICATIOXS    FOR   OPERATIOX  59 

physical  conditions  permit  of  it.  No  young  man  or  woman  is  doing  instice 
to  his  or  her  development  and  health  by  nursing  a  rupture  during  school 
and  college  life,  let  alone  the  many  ri,sks  incidentalh'  encountered  on  the 
playground  and  campus. 

The  wearing  of  a  truss  produces  atrophy  of  the  muscular  and  apo- 
neurotic structures  in  the  hernial  region.  It  is  the  rule  for  hernias  to 
become  more  and  m.ore  unmanageable  on  account  of  the  thinning  out  and 
destruction  of  tissue  thus  caused.  Those  W'ho  wear  trusses  are  likely,  sooner 
or  later,  to  ask  for  surgical  relief,  either  on  account  of  the  inefficiency  of 
one  truss  after  another,  or  owing  to  the  increasing  size  of  the  hernia,  and 
the  tenderness  at  the  seat  of  the  rupture.  Active  young  boys  and  girls 
and  able-bodied  men  and  women  should  be  advised  to  submit  to  the  oper- 
ative treatment  even  when  a  truss  is  worn  without  comfort  and  efficiency, 
because  after  a  time  the  rupture,  in  the  vast  majority  of  cases,  will  enlarge 
and  become  rebellious  to  a  truss. 

]\Ien  between  fifty  and  seventy  years  of  age,  or  older,  depending  on 
their  physical  condition,  need  no  longer  hesitate  to  undergo  an  operation 
for  rupture,  providing  their  vital  organs  are  normal.  It  is  occasionally 
admissible  to  perform  the  radical  operation  for  hernia  at  the  same  time 
that  a  prostate  is  being  removed,  and  such  double  operations  as  herniotomy 
and  appendectomy ;  herniotomv  and  salpingectomy ;  herniotomy  and  h}'s- 
terectomy,  etc.,  through  the  same  incision,  are  not  uncommon  in  my  prac- 
tice. 

In  operative  procedures  generally  the  routine  of  the  operation  should 
be  done  rapidly ;  in  fact,  almost  automatically,  while  one  should  "hasten 
slowly"  when  handling  and  dealing  with  the  most  important  structures.  It 
must  be  remembered,  however,  that  it  is  worse  to  be  criminally  rapid  than 
to  be  criminally  slow.  Be  speedy  at  common  technic  and  even  tedious,  if 
need  be,  for  safety. 

Occupation. — The  more  laborious  the  occupation  of  the  ruptured,  the 
more  advisable  it  is  to  recommend  an  operation.  Let  them  live,  and  live  in 
bodily  comfort.  The  exertions  at  toil  or  sports  increase  intra-abdominal 
pressure  and  force  a  rupture,  inevitably,  to  increase  in  size.  Considering 
the  extensive  clinical  services  now  universally  afforded  to  the  public,  no 
person,  be  he  ever  so  poor,  need  continue  to  be  partly  or  completely  dis- 
abled by  a  hernia.  The  well-to-do  and  wealthy  classes  can  well  afford  to 
be  surely  and  safely  relieved  of  their  hernial  at'Mictions.  It  is  not  many 
years  ago  that  an  operation  for  the  radical  cure  of  hernia  was  accompanied 
by  manv  dangers,  complications,  relapses  and  fatalities.  It  is  a  proud 
achievement  of  surgery  to  chronicle  that  now  deaths  are  less  than  one- 
quarter  of  one  per  cent.,  complications  seldom  occur,  and  relapses  are 
exceedingly  rare. 

It  is  not  uncommon  for  men  in  middle  life,  who  are  the  subjects  of  (me 
or  two  inguinal  hernias,  to  present  themselves  for  advice.  Let  us  sav  that 
they  are  small,  reducible,  and  controllable  hernias,  with  but  slight  incon- 
venience resulting  from  the  wearing  of  a  truss,  and  that  their  work  is 
not  muscularlv   laborious,   and   the   dansrers  of   strangulation   are  guarded 


60  INDICATIONS    FOR   OPERATION 

against  as  much  as  possible.  It  must  be  remembered  that  no  person  who 
is  wearing  a  truss  is  free  from  danger,  for  any  extra  exertion,  as  lifting, 
running  to  catch  a  car,  jumping  off  and  on  conveyances,  and  a  thousand 
other  wavs  that  could  be  mentioned,  is  liable  to  pop  the  rupture  bv  the  truss 
and  strangulation  occurs,  probably  for  the  first  tim.e.  In  consideration  of 
this  one  fact,  it  is  safer  for  such  mildly  herniated  cases  to  spend  a  vaca- 
tion in  a  hospital  for  two  or  three  v."eeks  in  obtainn-cg  a  cure,  than  to  run 
the  risks  associated  with  an  ocean  voyage,  a  railroad  journey  across  the 
continent  or  a  hunting  and  lisliing  trip  into  the  wilderness.  Men  occupied 
in  the  public  service,  especially  in  the  army  and  navy,  in  whom  an  inguinal 
hernia  develops,  should  be  operated  on  without  delay.  It  is  certain  that 
these  acquired  ruptures  occur  in  men  whose  inguinal  regions  are  congen- 
itally  deficient  and  weak.  This  predisposition  being  present,  the  exciting 
cause  is  furnished  by  the  fatigue  and  labor  inseparable  from  their  calling 
in  life.  In  this  connection  it  would  be  interesting  to  ascertain  how  many 
old  soldiers  and  sailors  receive  a  pension  solely  on  account  of  the  presence 
of  a  hernia.  Great  care  should  be  exercised  in  the  physical  examination 
of  applicants  for  the  army  and  navy,  and  also  for  life  and  accident  insur- 
ance. The  indication  for  operation  on  these  individuals,  when  a  hernia  is 
found,  has  been  generally  conceded.  Some'  insurance  companies,  to  their 
discredit,  have  been  lax  in  this  regard. 

Obesity. — The  fact  that  a  person  is  obese  does  not  Jiecessarily  debar 
him  or  her  from  the  benefits  of  an  operation  for  hernia,  but  it  does  call  for 
an  early  operation  and  a  master  hand.  They  are,  of  course,  more  difficult 
to  operate  on  than  those  who  are  spare  or  muscular.  In  the  first  place,  they 
usually  take  any  anesthetic  badly,  and  especially  so  when  they  are  placed 
in  the  Trendelenburg  position,  which  is  often  necessary  to  keep  the  bowels 
and  great  omentum  well  away  from  the  field  of  operation.  Owing  to  the 
amount  of  superimposed  fat,  a  longer  incision  than  usual  is  also  required, 
in  order  to  expose  the  aponeurotic  and  muscidar  structures.  On  exposing 
the  internal  ring,  sac  and  cord,  redundant  fat  is  often  found  everywhere, 
sometimes  in  rolls.  The  sac  itself  may  be  fatty  or  have  fat  on,  along  or 
around  it,  making  it  difficult  to  differentiate  the  sac  or  suture  it  or  tie  it 
off.  Fatty  degeneration  of  the  aponeurosis  of  the  external  and  internal 
oblique  muscles,  and  of  the  conjoined  tendon,  may  be  marked,  which  makes 
the  structures  more  delicate  and  friable  than  usual.  The  fatty  degenera- 
tion just  mentioned  does  not  exist  so  markedlv  in  a  man  of  active  habits 
as  it  does  in  one  who  is  sedentary. 

This  brings  up  the  question  of  preparation  for  operation  for  hernia  on 
the  inactive  obese.  It  is  wise  to  reduce  the  flesh  by  exercise  and  proper 
diet,  whenever  circumstances  and  local  conditions  permit  such  a  reduction. 
Let  the  patient  eat  less,  walk,  run  or  work  more  than  usual.  If  he  is  a  beer 
drinker,,  exclude  the  beer.  In  behalf  of  surgeons  in  general,  and  espcciailv 
in  the  interests  of  the  patiexit,  I  am  constrained  to  advise  the  novice  in 
surgery  not  to  speak  lightly  of  obesity  in  connection  with  the  radical  opera- 
tion, or  even  to  undertake  the  operation.  The  amount  of  fat  to  be  removed : 
the  proper  coaptation  of  the  structures  to  ensure  the  success  of  the  opera- 


A5  Cleave  land. 


PLATE  X. 

Diaphragmatic  Hernia. 

(Peacock's  Case.) 

Transactions  Pathological  Society  of  London. 


INDICATIONS    FOR   OPERATION  .  6^ 

tion;  the  prevention  of  dead  spaces;  the  final  suturing;  when  and  when 
not  to  drain ;  the  apphcation  of  a  suitable  dressing  and  the  after-treatment 
all  demand  and  tax  the  experience,  skill  and  dexterity  of  a  master  sur- 
geon. A  doctor  is  not  a  surgeon  and  only  becomes  one  by  having  a  natural 
aptness  for  surgery,  and  by  acquiring  a  paijistaking  application  of  his  en- 
dowments. He  must  learn  and  have  at  his  command  a  full  and  complete 
knowledge  of  all  of  the  macro-  and  microscopic  conditions  demanding 
operation.  He  must  then  learn  how  to  cut  well,  clamp  nicely,  tie  quickly 
and  saf.^ly,  mop  at  the  right  time,  and  sew  not  too  loosely,  not  too  tightly, 
but  just  right.  In  surgery  experience  never  teaches  fools.  I  have  seen 
the  ''would  be"  surgeons  guilty  of  the  same  errors  even  when  pointed  out 
again,  again  and  again,  ad  inHnitum. 

Conditions. — There  are  many  conditions  of  an  oblique  hernia  that  de- 
mand operation  without  delay.  These  will  be  taken  up  more  fully  later  on 
in  this  work.    In  the  meantime  it  is  v/ell  to  enumerate  them,  as  follows : 

1.  Unmanageableness. 

2.  Irreducibility. 
Inflammation. 
Incarceration. 
Strangulation. 
Rupture  by  a  blow  or  fall. 

In  regard  to  the  size  of  the  hernia,  I  must  say  that  sometimes  a  small, 
troublesome  one  is  more  dangerous  than  a  large,  quiet  one.  Quiet  is  a  good 
adjective  when  the  hernia  is  easily  reducible  and  immediately  returns,  lying 
calmly  in  the  scrotum  without  any  pain  whatever.  The  very  large  hernias, 
those  extending  down  on  the  thigh  to  near  the  knee,  are  usually  classed 
as  inoperable.  We  sometimes  are  obliged  to  operate  on  them  when  they 
become  strangulated,  and  then  we  succeed  in  curing  the  hernia.  An  ex- 
perienced, expert  operator  very  seldom  refuses  to  operate  on  account  of  the 
large  size  of  the  rupture,  even  though  it  is  incarcerated. 

Cryptorchidism. — In  retentio  ingninalis  testis  a  hernia  is  alwa\s  pres- 
ent, and  it  ought  to  be  cured  by  operation.  AVhen  the  testicle  is  retained, 
within  the  abdomen  surgeons  differ  as  to  whether  or  not  an  attempt  should 
be  made  to  bring  the  organ  down  into  the  scrotum,  even  though  a  hernia  is 
not  present.  In  my  own  experience,  a  congenital  deficiency  in  the  inguinal 
region  has  always  been  present  in  the  cryptorchid,  hence  I  have  not  hesitat- 
ed to  enter  this  region,  bring  the  testicle  to  its  normal  position,  and  cure 
the  hernia,  even  though  it  may  have  been  of  small  size. 

It  is  in  this  connection  that  I  make  use  of  the  Fowler  operation  for 
oblique  inguinal  hernia,  with  the  exception  of  incising  the  peritoneum  be- 
hind the  cord.  The  peritoneum  is  dissected  away-  from  the  transversalis 
fascia  and  sutured,  or  tied  separately.  This  allows  the  vas  deferens  a 
shorter  route  than  normal  between  the  seminal  vesicles  and  the  testes. 

It  must  be  recognized  that  heretofore  operations  on  the  non-descended 
testicle  have  not  been  very  satisfactory.  Failures  in  bringing  down  the 
testicle  were  frequent  and  about  fifty  per  cent,  of  the  hernias  relapsed, 
consequently  surgeons  avoided  the  operation.     Now  that  plastic  procedures 


64  .  INDICATIONS    FOR   OPERATION      ' 

can  be  used  to  strengthen  this  congenitally  weak  region,  recurrences  are 
exceedingly  rare.  No  relapse  has  occurred  in  any  cases  of  hernia  com- 
plicated with  cryptorchidism  on  which  I  have  operated  in  the  past  seven 
years. 

DIRECT  INGUINAL  HERNIA. 

The  indications  for  operating  on  a  direct  inguinal  hernia  are  prac- 
tically the  same  as  those  given  for  the  oblique  variety,  but  inasmuch  as  a 
truss  does  not  well  retain  this  form  of  hernia,  the  sooner  the  operation 
is  performed  the  better.  A  congenitally  weak  Hesselbach's  triangle  Is 
weakened  still  more  by  the  application  of  a  truss,  and  when  this  condition  is 
permitted  to  exist  for  years  the  conjoined  tendon  becomes  obliterated  al- 
most entirely.  In  order  that  this  region  may  be  strengthened,  the  sur- 
rounding structures  are  made  use  of,  such  as  the  rectus  muscle  on  the  one 
side  or  the  sartorius  muscle  on  the  other. 

UMBILICAL  HERNIA. 

Umbilical  hernia  in  children  under  two  or  three  years  of  age  is  often 
practically  cured  by  the  application  of  a  pad  or  truss.  If,  at  any  time,  the 
hernia  becomes  unmanageable,  there  is  no  valid  reason  for  delaying  opera- 
tion. If  the  operation  is  not  performed  early  in  these  cases,  the  diastasis 
of  the  recti  muscles  constantly  increases,  and  when  the  operation  finally 
is  undertaken  it  is  a  much  more  radical  and  grave  procedure. 

The  radical  cure  of  a  small  umbilical  hernia  is  a  very  simple  procedure, 
consisting  merely  of  the  removal  of  the  umbilicus,  an  omphalectomy,  and 
splitting  the  sheaths  of  the  two  recti  muscles,  obliterating  the  linea  alba 
above  and  below  the  umbilicus. 

No  umbilical  hernia  should  be  allowed  to  become  incarcerated.  Just 
as  soon  as  it  is  irreducible,  whether  the  hernia  is  small  or  large,  operation 
should  be  advised.  All  active  young  persons  the  subjects  of  an  umbilical 
hernia  should  be  operated  on  at  the  earliest  possible  moment. 

Women  who  are  bearing  children  and  who  have  an  umbilical 'hernia, 
even  a  large  one,  need  not  be  operated  on  until  the  child-bearing  period 
is  passed,  provided  the  hernia  does  not  give  rise  to  any  dangerous  symp- 
toms. Umbilical  hernias  giving  rise  to  pain,  intestinal  disturbance  or 
symptoms  of  strangulation  should  be  operated  on  without  delay.  Since  the 
overlapping  operation  of  Mayo  and  Blake,  and  modifications  of  these  opera- 
tions, have  been  devised,  excellent  results  are  obtained.  Even  obesity  is  not 
a  contra-indication  to  operation  for  umbilical  hernia.  A  large  amount  of 
the  abdominal  fat  may  be  removed  at  the  same  time  and  the  patient  thus 
made  more  comfortable  and  placed  in  better  physical  condition. 

Hernia  into  the  umbilical  cord   (funicular  hernia)   is  of  very  rare  oc-  . 
currence,  the  author  having  seen  only  one  case.     It  should  be  operated  on  at 
once,  because  the  child  will  surely  die  if  operation  is  not  done. 

Supra-  sub-  and  para-umbilical  hernias  when  small  may  be  cured  with- 
out removing  the  navel. 


INDICATIONS   FOR   OPERATION  05 

FEMORAL  HERNIA. 

Of  all  the  hernias  of  the  anterior  abdominal  wall,  the  femoral  or  crural 
hernia  is  the  most  dangerous  because  of  its  tendency  to  become  strangulated. 
A  femoral  hernia  is  not  easily  controlled  by  any  form  of  truss  or  mechanical 
device.  It  usually  slips  from  under  the  truss  several  times  a  day  until  the  pa- 
tient becomes  discouraged,  leaves  off  the  truss,  and  perhaps  the  very  next 
day  the  hernia  becomes  strangulated.  Therefore,  on  account  of  the  clinical 
history  of  femoral  hernia,  operation  should  be  advised  in  every  instance. 

VENTEAL  HERNIA. 

Ventral  hernia,  in  mid-line,  below  the  umbilicus,  almost  invariably 
follows  an  abdominal  section  or  an  operation  on  the  bladder.  These  her- 
nias should  be  operated  on  as  soon  as  they  are  detected.  If  possible,  it  is 
better  to  remove  the  entire  old  scar  tissue,  split  the  sheaths  of  the  recti 
muscles  and  bring  like-to-like  structures  in  careful  approximation. 

In  this  region  there  are  so  many  ways  in  which  material  can  be  used 
to  strengthen  the  abdominal  wall  that  the  surgeon  need  have  no  hesitation 
in  recommending  operation.  Inasm.uch  as  adhesions  between  the  great 
omentum  and  the  abdominal  scar  are  always  present,  care  should  be  taken 
not  to  denude  the  peritoneal  surface  in  dealing  with  them.  It  is  here  that 
Downes'  electro-thermo-cautery  is  of  great  value.  A  strip  of  tissue  is 
cooked  and  severed  in  its  center  and  both  the  proximal  and  the  distal  stumps 
are  allowed  to  drop  back  into  the  abdominal  cavity,  v/ithout  the  fear  of 
adhesions  forming  later  on.  However,  a  practical  surgeon  can  always  cover 
over  any  raw  surfaces  so  as  to  prevent  these  adhesions  from  again  forming". 
It  is  rare  for  a  ventral  hernia  to  develop  in  the  linea  alba  beloAv  the  um- 
bilicus, but  when  it  does  arise,  operation  is  the  only  means  of  cure. 

Ventral  hernias  through  the  recti  muscles  are  very  rare.  They  always 
follow  a  trauma.  These  hernias  are  cured  easily  and  there  is  no  contra- 
indication to  operation.  Hernias  following  gall-bladder  and  stomach  opera- 
tions are  seldom  encountered. 

HERNIAS  FOLLOWING  APPENDECTOMY. 

These  hernias  sometimes  are  verv  difficult  to  handle  on  the  operating^ 
table.  Unless  the  patient  is  in  a  condition  to  stand  a  prolonged  anesthesia,, 
of  an  hour's  duration  at  least,  he  should  not  be  operated  on  unless  an  opera- 
tion is  demanded  because  of  the  existence  of  strangulation  of  the  bowel.. 
In  a  case  operated  recently  by  the  author  the  chief  indication  for  operation 
was  pain  extending  down  to  the  testicle.  At  the  operation  it  was  found 
that  the  cecum,  the  ascending  colon  and  several  loops  of  small  intestine  and 
some  omentum  were  adherent  to  the  ureter,  kidney,  liver,  gall  bladder  and 
stomach. 

EPIGASTRIC  HERNIA. 

These  hernias  are  usually  quite  small  and  consist  of  fat,  although  oc- 
casionally a  small  knuckle  of  stomach  or  bowel  is  found  in  the  hernial  sac. 
If  they  give  rise  to  any  considerable  inconvenience,  they  should  be  treated 


66  INDICATIONS    FOR   OPERATION 

surgically.  It  is  very  seldom  that  the  transverse  colon,  omentum  or  stom- 
ach form  the  contents  of  the  hernial  sac,  except  when  the  protrusion  is 
immediately  above  the  umbilicus. 

OBTURATOR.  ISCHIATIO  AND  PERINEAL  HERNIAS. 

(Downward  Hernias.) 

So  far  as  indication  for  operation  is  concerned  in  the  case  of  these 
hernias,  they  are  the  same  as  those  given  for  the  internal  hernias,  dia- 
phragmatic hernia,  hernia  through  the  foramen  of  Winslow  (foraminal), 
through  the  jejunal  fossa,  the  sigmoid  fossa  and  through  the  ileo-cecal 
fossa.  The  usual  indication  for  operation  in  all  these  forms  of  hernia  is  the 
appearance  of  symptoms  of  partial  or  complete  obstruction  of  the  bowel. 
The  abdomen  should  be  opened  without  delay,  the  obstruction  sought  and 
the  condition  rectified. 

A  few  cases  of  obturator  hernia  have  been  diagnosed  before  operation 
and  cured  without  an  abdominal  section  by  cutting  down  on  the  femoral 
region,  going  through  the  pectineus  muscle,  reaching  the  hernia  in  that 
way  and  producing  reposition  of  the  bowel. 

DIAPHRAGMATIC  HERNIA. 

Diaphragmatic  hernia,  the  acquired  variety,  produces  symptoms  refer- 
able to  the  thoracic  cavity,  which  makes  the  diagnosis  comparatively  easy. 
An  operation  should  be  performed  without  delay  in  all  these  cases,  pro- 
vided there  is  not  a  marked  contra-indication,  such  as  disease  of  the  stom- 
ach, intestines,  peritoneum,  kidneys  or  heart. 

Lumbar  hernia  is  diagnosed  easily,  but  as  it  does  not  usually  cause  any 
feeling  of  distress  or  discom^fort,  an  operation  is  not  urgently  demanded. 

VESICAL  HERNIA. 

The  urinary  bladder  may  protrude  through  Hesselbach's  triangle  alone 
or  together  with  other  abdominal  viscera.  An  operation  is  always  indicated 
in  this  form  of  hernia,  provided  the  patient  is  otherwise  in  good  health. 

Hernia  of  the  bladder  into  the  rectum  is  exceedingly  rare.  The  author 
has  seen  one  case,  and  no  case  is  recorded  in  the  literature. 

INTERNAL  HERNIAS. 

The  indications  for  operations  on  hernias  through  the  abdomen  are 
made  most  clear  after  the  abdominal  cavity  has  been  opened  or  a  post- 
mortem has  been  performed.  It  is  not  in  accord  with  the  science  of  sur- 
gery to  rely  entirely  on  these  two  sources  for  reasons  why  an  operation 
should  be  performed.  It  does  not  appeal  even  to  the  ordinary  sufferer  to 
be  told  that  the  diagnosis  of  his  case  will  be  made  after  the  abdomen  is 
opened.  If  we  cannot  make  a  diagnosis  of  these  ruptures  without  expos- 
mg  the  abdominal  contents  to  sight  and  subjecting  them  to  handling,  it  is 
because  of  our  ignorance  of  the  multiple  relationship  between  concealed 
hernia  and  its  symptoms  and  signs.  I  must  admit  that  our  present  posi- 
tion on  this  question  is  that  too  often  we  can  only  declare  that  our  experi- 


PLATE  XL 

Isc'hiatic  Hernia. 

Parks'  Surgery  of  American  Authors. 


IXDICATIOXS    FOR   OPERATI(3X  69 

ence  and  knowledge  are  too  limited  and  scant  to  enable  us  to  make  a 
positive  and  accurate  diagnosis ;  hence  we  advise  an  exploratory  incision. 
How  can  it  be  otherwise? 

The  exploration  of  the  abdominal  cavity  should  only  be  recommended 
when  by  other  means  of  investigation  we  have  failed  to  clear  up  the  case  and 
the  patient  is'  in  imminent  danger  of  losing  health,  if  not  life,  from  want  of 
surgical  attention.  While  it  is  of  great  value  to  the  surgeon  to  hold  a  post- 
mortem on  a  person  dead  of  an  internal  hernia  without  an  operation  \vhich 
should  have  been  performed  with  the  probability  of  having  been  discovered 
and  cured,  it  is  clear,  however,  that  no  benefit  whatever  is  given  to  that  par- 
ticular patient  by  a  study  of  the  changes  that  caused  his  death.  It  is  often 
more  difficult  to  obtain  the  consent  of  relatives  for  an  autopsy  than  it  is  to 
secure  that  of  a  sufferer  for  an  operation.  To  operate  on  all  obscure  intra- 
abdominal conditions  is  more  praiseworthy  than  to  let  a  single  person  die  be- 
cause of  failure  to  operate.  The  former  may  add  something  valuable  to  our 
knowledge  and  may  save  life,  while  inactivity  casts  a  reflection  on  the  sur- 
geon, and  on  his  profession,  and  begets  lack  of  confidence  in  medicine  and 
surgery  in  the  minds  of  the  general  public. 

When  an  abdomen  is  opened  an  object-lesson  is  at  once  presented,  in 
which  are  found  conditions  that  are  coupled  with  the  symptoms  and  signs 
previously  complained  of  and  manifested.  If  the  patient  recovers,  the 
subsidence  of  the  manifestations  of  the  disease  affords  us  proof  of  the  jus- 
tification of  the  operation.  During  the  operative  procedure  the  etiologic 
factors  are  caught  red-handed,  so  to  speak,  and  the  living  pathologic  condi- 
tions are  revealed,  each  stage  having  reflected  its  shadowy  symptoms  and 
signs,  and  the  real  cause  is  before  our  eyes  and  in  our  hands.  Advantages 
are  here  afforded  for  the  development  of  a  new^er  pathology  and  the  appli- 
cation of  bacteriology.  In  the  abdominal  surgery  of  hernias  too  many  in- 
stances of  deaths  from  lack  of  a  prompt  and  true  interpretation  of  the 
indicia  are  recorded  in  our  annals.  The  strategy  of  the  surgeon  has  more 
scope  in  the  abdominal  field  than  elsewhere  in  the  body,  on  account  of  the 
many  important  organs  within  one  cavity  that  are  interdependent  in  health 
and  in  disease.  A  bird's  eye  view%  as  it  were,  of  the  condition  of  the  pa- 
tient, and  especially  of  the  affected  region  and  organ,  must  be  taken  by  a 
general  surgeon,  or  surgeon  general,  before  he  can  advise  wisely  and  act 
strategetically. 

Pain  is  an  important  symptom  in  the  diagnosis  of  intra-abdommal 
conditions,  and  is  present  in  almost  every  ailment.  It  is  increased  by  pres- 
sure in  inflammation  of  any  part  of  the  body.  Pressure  on  an  over- 
distended  gallbladder,  appendix.  Fallopian  tube,  or  internal  strangulated 
hernia,  increases  the  pain.  When  it  is  "stitch-like"  or  "lancinating"  in 
character,  the  peritoneum  is  invaded,  or  a  cancer  may  be  present. 

What  is  termed  "reflected"  and  "radiated"  pain  is  misleading.  The 
irritation  of  one  branch  of  a  sensory  nerve  may  be  referred  (reflected)  to 
another  branch  of  the  same  trunk  and  felt  at  its  distribution,  or  may  be 
referred  to  all  the  terminations  of  all  the  branches  of  the  main  nerve. 

The    best    illustration    of    a    "radiated    pain"    is    seen    in    connection 


70  IXDICATIOXS    FOR    OPERATION 

with  the  trifacial  nerve.  A  dying  or  intiamed  nerve  pulp  of  a  tooth  in  the 
upper  jaw  may  cause  pain  to  be  referred  to  a  tooth  in  the  lower  jaw,  or 
to  all  the  teeth  in  both  jaws,  or  finally  to  the  entire  distribution  of  all  the 
branches  of  the  main  nerve.  In  the  abdomen  the  pain  of  an  inflamed  ap- 
pendix is  often  referred  to  the  whole  abdomen ;  that  caused  by  obstruction 
of  a  ureter  to  the  testicle :  that  of  an  obstructed  cystic  duct  to  the  back  and 
episgastric  region. 

Pain  produced  by  a  stone  in  the  pelvis  of  one  kidney  and  referred  to 
the  other,  kidney  is  explained  by  the  irritation  causing  congestion  of  the 
grav  matter  across  the  cord  which  forms  a  connection  with  the  innervation 
of  the  other  kidney.  When  a  nerve  trunk  is  primarily  irritated,  peripheral 
pain  is  felt  of  a  neuralgic  character,  e.  g.,  neuralgic  pain  in  the  distribution 
of  the  genito-crural,  ilio-hypogastric,  ilio-inguinal  and  anterior  crural  nerves, 
and  this  is  indicative  of  pressure  on  or  irritation  of  the  lumbar  plexus  by  a 
perinephritic  abscess  or  a  tumor  of  the  kidney. 

In  suppuration  the  pain  is  "throbbing,"  and  in  superficial  inflammation 
it  is  "burning"  or  "scalding."  The  older  writers  described  no  less  than 
forty-four  dififerent  kinds  of  pain,  in  accordance  with  the  sensations  ex- 
pressed by  various  sufferers. 

Pain  is  conspicuous  in  intestmal  obstruction  and  in  obscure  hernias.  It 
is  caused  by  the  trauma  to  the  peritoneum.  Peristaltic  action  tries  to  over- 
come the  obstruction  and  increases  the  suffering.  It  comes  and  goes  with 
irregular  contractions,  and  is  known  as  'colic."  The  colicky  pain  of  inter- 
nal hernias  when  obstructed  is  griping,  twisting  or  dragging  in  character, 
and  is  recognized  by  the  patient  to  be  in  his  bowels.  During  the  paroxysm 
he  describes  it  as  "fearful."  Something  is  felt  to  raise,  distend  and  move 
within  him,  which  always  becomes  arrested  at  a  certain  point.  He  knows 
and  feels  that  the  bowels  are  obstructed.  A  firm  conviction  is  expressed 
that  if  flatus  could  be  passed  the  pain  would  at  once  be  relieved.  This 
description  is  characteristic  of  early  and  incomplete  obstruction,  but  when 
it  becomes  complete  the  pain  abides  constantly.  The  progress  of  the  malady 
can  be  .fairly  well  judged  by  the  pain  becoming  more  and  more  continuous 
as  the  obstruction  increases. 

In  the  early  stages  the  abdomen  may  be  thoroughly  manipulated  and 
pressed  without  much  exaggeration  of  the  pain.  In  fact,  firm  pressure  is 
often  grateful  to  the  patient.  The  coincidence  of  tenderness,  pyrexia  and 
tympanites  bespeaks  the  onset  of  peritonitis.  A  time  comes  toward  the 
termination  of  a  fatal  case  when  the  pain  is  markedly  diminished  in  sever- 
ity. It  may  mean  that  perforation  has  occurred ;  the  sensorium  has  become 
less  active;  or  paralysis  of  the  intestine  has  come  on  from  over-distention 
or  peritonitis.  If  the  bowel  has  ruptured,  and  its  contents  are  poured  into 
the  general  peritoneal  cavity,  great  collapse  is  present,  but  when  the  escape 
is  into  some  other  part,  the  collapse  may  not  be  at  all  marked.  When  the 
pain  is  increased  by  taking  food,  or  after  an  enema  or  a  rectal  examination, 
it  shows  that  peristaltic  movements  are  still  capable  of  reflex  excitation. 

While  in  obstruction  of  the  pylorus  and  large  bowel  the  pain  may  be 
accurately  located  by  the  patient  at  the  seat  of  trouble,  it  is  not  so  when 


INDICATIONS    FOR   OPERATION  /I 

the  affection  is  in  the  small  intestine.  Distal,  medial  and  proximal  coils  of 
small  bowel  which  lie  side  by  side  are  constantly  changing  position,  and 
inasmuch  as  they  are  not  supplied  with  special  nerves,  it  is  impossible  for  the 
patient  to  locate  his  painful  sensations.  When  the  pain  of  a  strangulated 
hernia  is  associated  with  a  tender  and  fixed  spot  early  in  the 
disease,  depend  upon  it  that  the  constriction  is  in  bowel.  But 
when  the  strangulated  loop  becomes  inflamed  and  then  fixed,  a 
tender  and  a  fixed  spot  is  to  be  found.  The  referred  initial  pain  in  intes- 
tinal obstruction  is  usually  in  the  region -of  the  navel,  which  corresponds  to 
the  great  nerve  center  of  the  abdomen — the  solar  plexus.  Whether  a  loop 
of  jejunum  is  strangulated  in  the  duodeno-jejunal  fossa,  in  the  iliac  fossa, 
or  down  deep  in  the  pelvis,  the  first  pains  are  usually  referred  to  the  umbil- 
icus. Sometimes  the  early  pain  of  obstruction  of  the  bowel  is  referred  to 
the  opposite  side  corresponding  somewhat  to  the  inferior  mesenteric  plexus. 

Powerful  intestinal  contractions  may  cause  unbearable  pain,  the  suf- 
ferer doubling  up  spasmodically  and  crying  out.  A  few  months  ago  I 
was  called  to  the  Chicago  Hospital  after  midnight  to  operate  on  a  strong 
young  lady  said  to  be  suffering  from  obstruction  of  the  bowels.  A  lady 
friend  told  her  twenty-four  hours  previously  to  take  a  couple  of  ounces  of 
cascara.  She  took  it  all  in  one  dose,  which  produced  a  condition  simulating 
intestinal  obstruction.  She  was  purged,  of  course ;  when  I  saw  her  she  was 
passing  some  blood  and  mucus  per  anum.'  She  was  vomiting  bile  and  the 
contents  of  the  small  bowel  every  few  minutes.  Both  knees  were  drawn 
up.  The  abdominal  muscles  were  retracted  and  extremely  rigid.  Paroxysms 
of  pain,  torturing  in  character,  came  and  went  concomitantly  with  vomiting, 
crying,  increased  muscular  rigidity  and  straining  to  stool,  v/ith  inabihty  to 
'  pass  flatus.  At  times  the  straining  was  not  unlike  that  accompanying  an 
abortion,  and  the  fact  that  she  was  menstruating  added  to  the  complexity 
of  the  case.  There  was  a  constant  diffuse  pain  in  the  abdomen  as  well.  Her 
facial  expression  was  that  of  extreme  suffering  during  the  paroxysm,  but 
it  was  not  anxious.  The  pulse,  temperature,  blood  and  urine  were  normal. 
It  required  chloroform  during  the  paroxysms  to  relax  the  intestinal  and 
abdominal  contractions,  in  addition  to  large  doses  of  morphine.  The  pain 
and  spasms  did  not  entirely  cease  for  over  three  days.  I  stayed  at  her 
bedside  for  several  hours,  and  were  it  not  for  the  fact  of  the  chloroform 
allaying  the  vomiting,  muscular  spasms  and  rectal  tenesmus,  and  restoring 
mental  quietude,  which  enabled  me  to  make  several  careful  examinations  of 
the  abdomen  by  palpation,  percussion  and  auscultation  (not  neglecting  to 
examine  throug'h  the  rectum  and  vagina),  I  should  probably  have  diagnosed 
the  case  as  one  of  intussusception  or  internal  hernia. 

Abdominal  pains  are  often  caused  by  extra-abdominal  causes,  such  as 
those  of  Pott's  disease,  spinal  diseases,  malignant  disease  of  the  vertebrae, 
aneurysm  of  the  thoracic  aorta  close  to  the  diaphragm,  and  the  abdominal, 
hepatic,  gastric  and  renal  crises  of  locomotor  ataxia  must  be  considered. 

Colic  and  pain  are  associated  with  intoxications  from  impure  ingesta, 
lead  poisoning,  uremia,  morphin,  etc.  Hysterical  abdominal  pain  simulates 
peritonitis,  appendicitis,  gallstones,  intestinal  obstruction,  hernias,  and  many 


72  INDICATIONS   FOR  OPERATION 

other  conditions.  Pain  is  sometimes  referred  to  the  region  of  the  appen- 
dix in  the  initial  stages  of  pneumonia  and  pleurisy.  In  angina  pectoris  the 
pain  is  often  felt  below  the  ensiform  cartilage.  Pain  arising  from  disease  of 
the  liver,  pancreas,  suprarenals,  kidneys,  spleen  and  pelvic  organs  is  not 
infrequently  referred  to  the  abdomen.  Osier  {Johns  Hopkins  Hosp.  Bulle- 
tin, July  and  August,  1904)  has  grouped  certain  cases  as  follows:  i.  Those 
in  which  the  colic  occurs  in  connection  with  a  pure  angio-neurotic  edema 
(Quincke's  disease).  2.  Those  in  which  the  skin  lesion  is  simply  an  urti- 
caria, and  the  pain  supposed  to  be  a  colic  may  really  be  part  of  a  nervous 
affection.  3.  A  class  which  develops  arthritis  with  erythema,  purpura  and 
colic,  defined  by  Henoch,  and  known  by  bis  nam.e.  4.  There  are  cases  in 
which  the  lesions  are  multiform  erythema  with  or  without  edema,  asso- 
ciated with  more  or  less  redness  and  purpura.  5.  A  remarkable  group  of 
cases  with  only  recurring  colic. 

The  surgical  and  neurotic  aspects  of  these  conditions  are  worthy  of 
serious  consideration,  in  order  to  avoid  a  laparotomy  for  a  case  of  doubtful 
abdominal  colic. 

Pain  is  the  most  common  cry  of  distress  from  the  outraged  highest 
form  of  animate  creation — man,  and  its  meaning  has  been  so  frecjuently 
misinterpreted,  especially  in  cases  of  hernia,  when  a  diagnosis  can  be  made 
only  by  abdominal  section,  that  it  claims  the  surgeon's  most  serious  thought. 

It  is,  of  course,  understood  that  abdominal  pain  of  itself  cannot  be 
taken  as  an  invariable  indication  to  open  the  abdomen  in  these  cases.  Many 
other  symptoms,  as  well  as  the  signs  of  the  condition,  should  be  considered, 
such  as  tenderness  on  pressure,  hyperesthesia,  colic,  tympany,  nausea  and 
vomiting,  diarrhea,  localized  swelling,  friction  and  gas  sounds,  increasing 
leucocytosis,  collapse,  fever,  spasm,  visible  peristaltic  action,  meteorism, 
quantity  of  urine,  indicanuria,  and  other  symptoms  too  numerous  to  mention 
here,  as  well  as  the  onset,  duration  and  clinical  behavior  of  the  disease. 


CHAPTER  VII. 

PREPARATION  OF  THE  PATIENT. 

Time.  The  time  consumed  for  the  preparation  of  the  patient  should 
depend  on  the  emergency  of  the  case  and  the  constitutional  condition  of 
the  patient.  The  emergencies  met  with  in  hernia  cases  are  those  which  are 
associated  with  strangulation.  As  has  been  stated  before,  when  strangu- 
lation exists  the  operation  should  be  done  at  once,  irrespective  of  whether 
or  not  the  patient  can  be  prepared  properl}-.  In  the  vast  majority  of  cases 
twenty-four  hours  is  sufficient  time  for  proper  preparation.  When  two  or 
three  days  are  required,  it  is  to  counteract  some  constitutional  condition. 

Diet  and  Drink.  In  robust  and  healthy  men  and  women,  the  diet 
should  be  restricted  for  a  few  days  before  operation.  A  liquid  diet  is  best 
and  stimulants  must  be  prohibited  absolutely.  If  the  patient  has  been  in 
the  habit  of  taking  stimulants,  sufficient  time  should  elapse  for  the  elim- 
ination of  the  alcohol.  It  is  better  to  operate  when  the  circulatory  system 
of  the  patient  is  filled  with  water. 

If  the  kidneys  are  not  functionating  properly,  if  the  amount  of  urine 
excreted  is  scanty,  or  abundant,  the  amount  of  liquids  ingested  should  be 
regulated  accordingly. 

Purgation.  There  should  be  neither  too  much  nor  too  little  purgation. 
When  the  patient  is  purged  too  much,  the  system  is  depleted  too  rapidly, 
and  the  endurance  is  lessened  materially.  When  there  is  not  enough  purging 
done,  the  alimentary  tract  is  not  emptied  completely,  thus  favoring  auto- 
intoxication and  bacillary  infection.  There  are  two  varieties  of  bacilli  in  the 
alimentary  canal  that  are  likely  to  cause  serious  disturbance  in  the  wound 
after  operation.  One  of  these  is  the  colon  bacillus,  and  the  other  is  the  gas 
bacillus.    When  the  latter  germ  is  present  death  of  the  patient  usually  ensues. 

Two  ounces  of  castor  oil  administered  on  the  evenmg  before  operation 
is  about  as  efficient  and  safe  a  purgative  as  can  be  given.  The  effect  of 
the  oil  is  largely  mechanical.  It  incorporates  the  germs  within  itself,  thus 
removing  them  from  the  intestinal  tract. 

If  more  than  twenty-four  hours  have  been  required  to  prepare  the 
patient,  purgation  can  be  carried  out  in  two  stages.  Calomel  is  given 
seventy-two  hours  before  the  operation,  and  is  followed  by  a  saline.  Pro- 
vided no  vegetables  have  been  given  the  patient,  any  purgative  may  be  used 
just  before  the  operation;  but  if  vegetables  have  been  allowed,  the  bowel 
must  be  emptied  thoroughly  before  the  operation  is  begun.  While  the 
patient  is  being  purged  it  is  advisable  to  give  one-thirtieth  of  a  grain  of 
strychnine  three  or  four  times  daily. 

Preparation  of  Hernia  Area.  In  all  cases  of  strangulation  of  the  bowel 
the  patient  is  taken  to  the  operating  room  without  previous  preparation  of 


74  PREPARATION  OF  THE  PATIENT 

the  hernial  area,  which  is  there  cleansed  thorong-hly  with  soap  and  water, 
scrubbing  vigorously,  is  then  washed  off  with  sterilized  water,  scrubbed 
again  before  shaving.  The  reason  for  preparing  the  skin  so  carefully  before 
shaving  is  to  obviate  skin  infection  by  the  razor.  After  the  parts  have 
been  shaved  they  are  again  washed  with  soap  and  water  and  gauze,  care 
being  taken  not  to  use  the  brush  too  vigorously  on  the  scrotum  or  labia, 
for  fear  of  blistering  the  skin.  The  soap  and  water  is  then  washed  off  wdth 
plain  water,  the  parts  dried  with  gauze,  after  which  they  are  washed  with 
70  per  cent,  alcohol  and  a  1-1,000  bichloride  solution,  or  some  other  suitable 
antiseptic  such  as  carbolic  acid  or  lysol.  All  this  can  be  done  by  the  operator 
while  the  patient  is  being  anesthetized,  and  at  the  same  time  his  own  hands 
are  undergoing  the  same  process  of  disinfection  as  that  to  which  the  her- 
nial area  is  being  subjected.  If  there  is  no  dearth  of  assistants  it  is  just 
as  well  to  relegate  this  process  of  disinfection  to  one  of  them. 

In  preparing  the  patient  for  a  deliberate  operation  for  hernia  a  general 
bath  is  given  first,  then  the  parts  are  scrubbed,  shaved,  and  otherwise 
prepared  as  described  above,  and  after  being  rendered  as  aseptic  as  possi- 
ble, a  compress  saturated  with  a  solution  of  bichloride,  1-2,000,  is  applied 
and  left  on  over  night.  This  wet  antiseptic  dressing  is  sufficient  to  dis- 
infect the  skin  and  to  prevent  sepsis  through  any  abrasions  that  might 
have  been  made  during  the  process  of  shaving.  This  is  very  important. 
Experience  has  shown  that  if  use  is  made  of  a  solution  of  bichloride  stronger 
than  i-2,OGO,  and  this  left  on  for  twelve  hours,  a  dermatitis  is  caused  in 
many  cases.  Of  course,  this  will  interfere  with  primary  union  of  the  wound 
edges  after  the  operation.  The  use  of  a  solution  of  carbolic  acid,  1-20,  or 
of  bichloride  of  mercury,  1-500,  as  is  recommended  by  some  operators, 
has,  in  my  hands,  proven  to  be  very  deleterious  to  the  skin  when  applied 
for  several  hours  by  wa}'  of  a  compress.  Alcohol,  when  applied  to  the 
external  genitalia  while  the  patient  is  awake,  causes  considerable  stinging 
and  smarting,  but  when  the  patient  is  asleep  it  can  be  used  very  freely 
and  to  good  advantage.  Ether,  on  the  other  hand,  when  used  on  the 
scrotum,  causes  a  most  excruciating  pain  due  to  the  contraction  of  the 
dartos,  and  even  when  the  patient  is  asleep,  the  irritation  caused  is  sufficient 
to  awaken  him,  unless  he  has  been  anesthetized  profoundly. 

Painting  the  parts  with  iodine,  as  practised  by  some  operators,  is  also 
objectionable,  because  it  produces  a  dermatitis  which  should  be  avoided.  I 
am  convinced  that  Harrington's  solution  is  excellent  for  disinfecting  the 
skin  when  the  operation  is  an  emergent  one,  but  it  is  too  strong  and  too 
irritating  to  be  applied  in  the  form  of  a  wet  compress  left  on  over  night. 

On  the  following  morning  the  patient  is  brought  to  the  operating  room, 
and  while  he  is  being  anesthetized  the  compress  is  removed,  and  the  field 
of  operation  is  gone  over  again,  choosing  any  one  of  three  methods : 
(i)  Soap,  water,  alcohol,  bichloride;  (2)  Ether,  alcohol,  bichloride; 
(3)  Harrington's  solution.    The  patient  is  then  ready  for  the  operation. 

Clothing.  Some  patients  object  very  strenuously  to  adopting  the  cloth- 
ing commonly  used  in  a  hospital,  and  I  am  firmty  convinced  that  the  nervous 
reaction  caused  by  insisting  on  a  complete  change  of  raiment  has   often 


ted  if  led     After  Qrej ,       ASC 


PLATE  XII. 

A.  Rectus  muscle.  B.  Transversalis  fascia.  C.  Poupart's  ligament. 
D.  Femoral  fascia.  E.  Psoas  and  iliacus  muscles.  F.  Pectineus  muscle. 
G.  Pubic  ramus.  H.  Gimbernat's  ligament.  I.  Septum  crurale.  J.  Iliac 
artery.  K.  Iliac  vein.  L.  Spermatic  vessels.  M.  Deep  hypogastric  ves- 
sels.   X.  Obturator  nerve  and  vessels.    O.  Vas  deferens. 

I.  Opening  of  internal  oblique.  2.  Opening  for  external  direct  hernia. 
3.  Opening  for  internal  direct  hernia.  4.  Openmg  for  femoral  hernia.  5. 
Opening  for  obturator  hernia.     6.  Obliterated  hypogastric  artery. 


PREPARATION  OF  TIIE  PATIEXT  77 

interfered  materially  with  a  smooth  convalescence  after  operation.  I  believe 
also  that  I  can  trace  several  cases  of  broncho  pneumonia  and  lobar  pneu- 
monia to  this  cause.  Therefore  it  is  advisable  to  take  into  consideration  the 
wishes  and  the  habits  of  the  patient  in  this  regard,  and  if  he  insists  on 
wearing  his  under-garments  this  should  be  permitted,  but  they  must  have 
been  thoroughly  disinfected  first. 

When  everything  is  ready  for  the  operation  the  patient  should  be  in- 
formed of  it,  not  too  soon  and  not  too  late,  however.  As  a  rule  it  is  prefer- 
able to  set  an  indefinite  time  for  the  operation,  so  as  to  avoid  undue  excite- 
ment. Tell  the  patient  that  the  operation  will  be  proceeded  with  when 
everything  is  ready.  In  the  case  of  a  very  nervous  patient  it  is  time  enough 
to  tell  him  on  the  m.orning  of  the  day  set  for  the  operation,  thus  not  depriv- 
ing him  of  a  sound  and  restful  sleep.  Many  patients,  if  informed  of  the 
time  of  operation  the  day  previously,  spend  a  wakeful  and  restless  night,  and 
hardly  are  in  condition  to  be  operated  on  in  the  morning.  Then,  too,  it  does 
not  give  the  patient  a  chance  to  procrastinate,  as  he  usually  is  inclined  to  do  " 
if  advised  too  soon  of  the  time  of  operation. 

The  Operator.  While  the  age  of  the  surgeon  does  not  per  se  always 
play  an  important  part  in  the  successful  conduct  of  an  operation,  still  it 
can  be  said  that  those  who  are  too  young  in  surgery  are  liable  to  rush  in 
heedlessly  and,  on  the  other  hand,  those  who  are  too  old  are  sometimes 
over-confident  in  their  ability,  which  breeds  carelessness.  In  this  country 
the  surgeon  works  in  the  operating  room  sometimes  to  a  very  old  age, 
when  it  is  lamentable  to  see  the  shaking  hand  and  to  notice  the  incomplete 
attempts  at  surgical  dexterity.  While  these  men  would  be  excellent  consult- 
ants in  an  operating  room,  they  are  really  no  longer  fitted  to  add  to  the 
advancement  of  the  art  of  surgery.  In  England  the  age  limit  for  the 
surgeon  is  placed  at  sixty ;  in  Germany  at  seventy ;  in  France  at  seventy- 
five,  while  in  Scotland  he  operates  as  long  as  he  is  able.  It  must  not  be 
forgotten,  however,  that  there  are  some  men  who  are  young  in  years  and 
old  in  surgery,  and  that  there  are  many  old  men  who  are  still  excellent 
operators. 

The  surgeon  should  have  sufticient  muscular  strength  to  endure  the 
hardships  encountered  in  performing  major  operations  day  after  day,  and 
often  night  after  night.  ]\Ianual  dexterity  also  is  an  essential  requirement. 
Some  individuals  possess  naturally  what  is  called  a  surgical  hand,  although 
no  person  is  endowed  naturally  with  sufficient  dexterity  to  do  surgical  work 
without  having  had  a  great  deal  of  preliminary  training.  The  training  of 
the  fingers  to  differentiate  tissues  is  an  acquirement  which  is  of  as  much 
importance  as  is  the  training  of  the  mind  to  know  what  to  do  and  when 
to  do  it. 

The  skill,  dexterity  and  nianpilative  ability  of  the  surgeon  should  be 
acquired  in  the  dissecting  room,  and  not  alone  in  the  operating  room.  The 
herniotomist  should  be  not  merely  a  good  general  surgeon,  he  should  have 
an  accurate  knowdedge  of  surgical  anatomy,  especially  the  surgical  anatomy 
of  hernia. 

The  surgeon  should  always  be  in  what  is  called  the  pink  of  condition. 


78  PREPARATION  OF  THE  PATIENT 

He  must  take  good  care  of  his  health,  and  keep  his  mind  and  body  clean. 
While  surg-ical  cleanliness  is  of  great  importance,  personal  cleanliness  also 
counts  for  much  if  he  would  be  a  successful  surgeon.  Right  living  is  an 
essential  to  success  in  surgery.  While  in  the  hospital  making  his  rounds, 
just  before  performing  an  operation,  the  surgeon  should  not  go  around 
and  shake  hands  with  everybody ;  in  fact,  it  is  better  not  to  visit  any 
patients  at  all. 

The  successful  surgeon  is  he  who  observes  all  those  small  details  which 
mean  so  much.  He  should  change  all  his  clothing  just  before  operating, 
taking  off  not  only  the  outer,  but  also  the  underclothing.  All  these  things 
have  a  direct  bearing  on  the  successful  healing  of  wounds,  and  on  the 
ultimate  result  of  the  operation.  After  being  thoroughly  ascepticized,  and 
properly  clothed,  the  surgeon  should  not  touch  anything  except  the  instru- 
ments and  materials  that  are  necessary  for  the  performance  of  the  operation. 

At  the  operating  table  the  surgeon  should  not  stand  stooped  over  his 
patient,  breathing  on  to  the  field  of  operation.  This  increases  the  liability 
of  infection.  He  should  stand  erect  and  as  far  away  from  the  wound  as 
is  consistent  with  the  work  to  be  done.  His  assistants  should  be  taught  to 
stand  erect  and  at  arm's  length  from  the  table.  Talking  should  be  pro- 
hibited and  all  the  breathing  should  be  done  through  the  nose.  When  it 
is  necessary  to  make  a  request  for  something  or  to  answer  a  question,  the 
surgeon  should  select  a  time  when  it  is  safe  for  him  to  turn  his  face  away 
from  the  wound.  When  these  precautions  are  taken,  it  is-  not  necessary 
to  wear  those  hideous  masks  which  soon  become  very  foul,  nor  is  there  any 
need  of  tying  up  the  mouth  with  gauze.  If  the  surgeon  prefers  to  wear  a 
mask,  it  is  advisable  to  change  it  several  times  during  the  operation. 

Assistants,  nurses  and  visitors  should  be  prohibited  from  talking  in 
the  operating  room,  especially  when  they  are  near  the  patient.  Unnecessary 
Avalking  in  the  operating  room  also  is  conducive  to  infection. 

In  the  amphitheatre  the  same  precautions  should  be  taken  as  in  the 
private  operating  room.  Of  course,  there  is  in  this  case  some  necessity  for 
talking,  because  students  are  there  for  the  purpose  of  being  instructed.  It 
is  not  enough  for  them  to  see ;  the  steps  of  the  operation  must  be  explained. 
The  conduct  in  the  amphitheatre  resolves  itself  into  three  parts:  (a)  Be- 
fore the  operation;  (b)  during  the  operation,  and  (c)  after  the  operation. 
Before  the  operation  a  short  lecture  can  be  given  on  the  nature  of  the  case; 
the  anatomical  structures  involved ;  the  diagnosis ;  the  selection  of  the  opera- 
tion ;  and  the  reasons  for  such  selection.  The  operator  can  make  the  initial 
incision  and  then  allow  his  assistants  to  pick  up  and  ligate  bleeding  vessels 
while  he  explains  to  his  audience  what  is  being  done.  Then,  turning  to  his 
patient,  he  continues  with  the  operation  until  he  reaches  a  point  in  the  pro- 
cedure where  it  is  possible  to  stop  for  a  few  minutes  to  permit  of  further 
explanation.  Finally,  he  completes  the  operation  in  its  essential  features, 
and  then  turns  the  patient  over  to  an  assistant,  who  carries  out  the  final 
steps,  such  as  suturing  the  skin  wound  and  applying  the  dressing. 

Surgical  coolness  is  an  admirable  quality.  Recklessness  often  is  mis- 
taken for  it.    Nervousness  of  the  surgeon  during  an  operation  is  inimical  to 


PREPARATION  OF  THE  PATIENT  79 

good  surgery.  There  are  surgeons  who  are  extremely  nervous  before  an 
operation,  but  who  during  the  operation  are  cool  and  collected.  The  sur- 
geon who  always  is  under  great  mental  and  bodily  strain  while  performing 
a  major  operation  should  give  up  the  work  entirely.  Anxiety  and  concern 
for  the  welfare  of  the  patient  are  all  well  and  good,  but  the  durgeon  should 
not  carry  them  to  the  extent  of  getting  rattled.  It  is  rather  ludicrous  to 
see  a  surgeon  of  international  reputation  perfonn  an  operation  for  the  radi- 
cal cure  of  hernia  and  become  so  confused  as  not  to  be  able  to  differentiate 
the  vas  deferens,  the  conjoined  tendon,  and  most  of  the  important  struc- 
tures in  that  area.  Not  long  ago  such  an  exhibition  was  given  in  one  of  the 
large  cities  of  this  country  when  the  surgeon  spent  fully  half  an  hour  try- 
ing to  push  back  the  omentum  and  bowel  with  his  fiagers,  forgetting  com- 
pletely that  these  structures  would  recede  of  themselves  bv  merely  placing 
the  patient  in  the  Trendelenburg  position.  Not  until  this  was  suggested  by 
the  anesthetist  was  it  done. 

As  a  rule,  the  instruments  for  the  operation  are  selected  by  the  sur- 
gical nurse,  the  assistant,  or  the  senior  interne.  While  tnis  lessens  the 
labor  of  the  surgeon  and  saves  time,  it  not  infrequently  leads  to  embarrass- 
ment when  the  surgeon  calls  for  an  instrument  and  finds  that  it  has  not 
been  prepared.  For  this  reason  the  surgeon  should  alwa3's  look  over  his 
instruments  before  commencing  an  operation. 

The  surgeon  should  learn  to  handle  his  own  instruments  during  the 
operation,  so  that  he  can  get  along  without  an  assistant.  By  this  means  he 
will  arrive  at  a  system  in  the  operating  room  which  will  lessen  the  number 
of  assistants  and  nurses  recjuired  during  operation. 

The  surgeon  of  to-day  is  quite  a  different  individual  from  his  proto- 
type of  twenty-five  years  ago.  He  gets  better  results.  He  does  not  oper- 
ate on  a  time  limit  nor  does  he  dash  off  a  herniotomy  without  taking  the 
time  necessary  to  examine  into  the  case  and  determine  the  conditions  to  be 
encountered.  He  does  not  perform  his  operations  by  routine,  but  adapts 
the  operation  to  the  individual  case.  The  most  brilliant  results  can  be  ob- 
tained if  the  surgeon  is  painstaking  and  operates  only  under  proper  condi- 
tions. 

Any  visitors  who  may  be  present  during  an  operation  should  be  so 
gowned  that  no  part  of  the  body,  except  the  head  and  feet,  is  exposed. 
The  writer  uses  for  this  purpose  a  sleeveless  gown,  a  sort  of  bag,  that  slips 
over  the  head  with  a  drawstring  at  the  neck.  It  reaches  down  below  the 
knees  and  completely  covers  the  body  and  prevents  the  use  of  the  hands. 

The  Operating  Room.  At  Home. — In  the  home  the  kitchen  is  us- 
ually the  most  suited  for  an  operating  room.  It  is  well  lighted  and  is  also 
the  cleanest  room,  unless  one  of  the  9ther  rooms  in  the  house  has  been  pre- 
pared specially.  Therefore  emergent  operations  performed  at  home  should 
be  done  in  the  kitchen.  If  there  is  sufficient  time  to  prepare  for  the  opera- 
tion any  room  can  be  gotten  ready.  Then  the  furniture  and  hangings  of  all 
kinds  should  be  rem.oved,  and  the  wails,  floor  and  windows  scrubbed  and 
then  gone  over  thoroughly  with  a  1-500  bichloride  solution.  The  night  be- 
fore the  operation  the  table  to  be  used  and  the  other  furniture  needed  dur- 


80  PREPARATION  OF  THE  PATIENT 

ing  the  operation  are  gone  over  in  the  same  way.  During  the  night  the  room 
should  be  fumigated  with  formaldehyde.  A  second  room  also  should  be 
made  reasonably  clean.  Here  most  of  the  preparatory  work  is  done,  such 
as  the  sterihzation  of  sheets,  towels,  and  water;  but  the  instruments  and 
materials  to  be  used  during  the  operation,  the  sponges  and  the  dressings, 
should  be  prepared  in  the  hospital. 

The  patient  should  not  be  carried  into  the  operating  room  until  he 
has  been  anesthetized.  If  the  room  is  large  enough  a  bed  may  be  put  into 
it  on  which  the  patient  is  placed  after  the  completion  of  the  operation,  and 
allowed  to  remain  until  he  has  recovered  from  the  effects  of  the  anesthetic. 
Then  he  is  carried  to  the  room  which  has  been  specially  prepared  to  re- 
ceive him.  » 

In  the  Private  Hospital.  The  room  which  is  to  be  used  for  an  oper- 
ating room  should  be  selected  very  carefully.  Inasmuch  as  all  the  deliberate 
operations  are  performed  in  the  morning,  there  is  no  objection  to  selecting 
a  room  with  a  west  exposure.  Nor  is  there  any  objection  to  selecting  one 
with  a  north  exposure,  except  that  it  usually  is  more  difficult  to  keep  this 
room  warm  in  the  winter.  South  and  east  exposures  should  never  be 
chosen. 

The  operating  room  should  be  properly  constructed  and  ventilated,  but 
above  all  things  it  should  be  kept  clean — that  is,  surgically  clean.  It  should 
be  scrubbed  and  made  aseptic  every  day  with  a  bichloride  solution.  The 
same  thing  should  be  done  between  operations,  if  more  than  one  operation 
is  done  on  the  same  day,  and  especially  after  a  septic  case  has  been  oper- 
ated on.  For  these  reasons,  as  well  as  for  many  others,  it  is  advisable  to 
have  two  operating  rooms  in  a  private  hospital.  Neither  of  these  should 
be  designated  as  the  septic  room,  because  if  one  room  is  selected  for  septic 
cases,  and  the  other  is  reserved  for  aseptic  cases,  there  is  the  danger  of 
allowing  the  former  to  become  foul,  thus  serving  as  a  nidus  of  infection  for 
the  clean  room.  Both  rooms  should  be  cleaned  every  day,  so  that  they  may 
be  ready  at  all  times  for  any  kind  of  an  operation  on  any  kind  of  a  case.  It  is 
a  good  plan,  however,  to  reserve  a  room  in  which  medicines  and  dressings 
can  be  kept.  This  room  may  be  situated  between  the  two  operating  rooms, 
for  the  sake  of  convenience. 

After  the  completion  of  a  septic  operation  the  operating  room  should  be 
cleaned  immediately  and  thoroughly  disinfected  with  formaldehyde,  so  that 
it  will  be  readv  for  use. 


CHAPTER  VIII. 

SURGICAL  BACTERIOLOGY. 

Aseptic  surgery  is  the  ideal  surgery.  It  assumes  that  before  operation 
the  tissues  of  the  patient  are  free  from  disease-producing  germs,  and  that 
the  surgeon  has  destroyed  the  germs  on  his  hands,  instruments,  Hgatures, 
and  other  material  used  during  the  operation.  The  exhaled,  vitiated  breath 
is  prevented  from  entering  the  wound  by  means  of  shields  of  gauze,  called 
masks,  which  are  placed  before  the  mouth  and  nose.  The  air  in  the  room 
should  be  dustless,  in  order  to  reduce  to  a  minimum  the  possibility  of  infec- 
tion occurring  from  the  entrance  into  the  wound  of  bacteria  contained  in 
the  dust.  There  is  no  reason  why  there  should  be  any  inflammation,  sup- 
puration, septicemia,  or  pyemia,  after  operative  procedures.  Clean  and 
careful  surgeons  have  eliminated  the  two  last-named  from  their  practice, 
but  inflammation  and  suppuration  are  still  with  us,  although  to  a  very  lim- 
ited degree. 

Ideal  aseptic  surgery  really  does  not  exist,  because,  strictlv  interpreted, 
the  term  means  that  there  are  no  germs,  no  infection,  and  no  interference 
with  the  healing  of  the  wound  by  germs.  The  air  is  laden  with  millions  of 
germs ;  beneath  the  finger-nails,  in  the  crevices  and  folds  of  the  skin,  even 
after  vigorous  scrubbing  with  soap  and  water  for  fifteen  minutes,  germs 
are  abundant.  Therefore,  there  can  be  no  such  state  as  asepticitv  of  the 
skin.  The  wound  is  always  exposed,  more  or  less,  to  air,  which  may  be  the 
source  of  infection,  to  the  contact  of  fingers,  instruments,  sutures,  dressings., 
etc.  If  the  surgeon  keeps  all  fingers,  except  his  own,  out  of  the  wound., 
the  danger  of  infection  is  minimized,  especially  if  he  takes  proper  aseptic 
and  antiseptic  precautions.  In  fact,  if  it  were  not  for  two  things  suppura- 
tion of  wounds  would  occur  much  more  frequently  than  it  does  now.  These 
are  (a)  the  antiseptic  properties  of  perspiration,  and  (b)  the  resisting  pow- 
ers of  the  patient. 

I  will  not  now  refer  to  the  assistants,  internes  and  nurses  in  this  con- 
nection, but  will  consider  only  the  two  parties  involved  primarily,  the  pa- 
tient and  the  surgeon,  because  infection  is  due  to  one  oi  the  other  of  these 
two.  The  patient  cannot  help  it,  but  the  surgeon  can.  The  surgeon  should 
hold  himself  responsible  for  everything  connected  with  the  operation,  for 
the  work  of  the  anesthetist  and  the  mistakes  of  his  assistants  and  nurses. 

Long  before  the  germ  theory  of  disease  was  promulgated  the  ad- 
vantages of  moist  dressings  w^ere  recognized.  They  keep  the  wound  sur- 
face clean  and  the  secretions  unsuitable  as  a  culture  medium  for  bacteria. 
Before  1866  Lister  had  as  much  sepsis  in  his  practice  as  most  other  sur- 
geons. During  the  subsequent  five  years  he  reduced  his  mortality  in  major 
amputations  from  42.7  per  cent,  to   11.25  per  cent.     To-day  the  mortalitv 


82  SURGICAL   BACTERIOLOGY 

from  infection  occurring  during-  the  performance  of  major  operations  is 
practically  nil.  For  a  clear,  accurate  and  vivid  description  of  the  surgery 
of  those  days,  contrasted  with  the  surgery  of  to-da}',  I  refer  the  reader  to 
Nicholas  Senn's  most  excellent  work  on  "Practical  Surgery." 

The  subject  of  bacteriology  is  so  inseparable  from  the  technic  of 
modern  operations  for  hernia  and  other  general  operative  procedures,  that 
the  surgeon  is  no  longer  "a  physician  w'ho  operates,"  but  he  must  be  one 
who  has  specially  prepared  himself  to  do  surgery,  and  no  small  part  of  his 
training  must  have  been  in  bacteriology.  As  many  excellent  books  have 
been  written  on  the  subject  of  bacteriology  the  author  does  not  think  it 
necessary  to  discuss  the  subject  at  any  great  length,  limiting  himself  only 
to  making  such  reference  as  will  serve  as  a  connecting  link  between  bac- 
teriology and  clinical  surgery. 

When  infection  occurs  following  a  herniotomy,  it  is  the  duty  of  the 
surgeon  to  determine  the  source  and  the  cause  of  such  infection.  Cultures 
should  be  made  from  the  discharges  of  the  wound  and  from  all  materials, 
including  instruments,  that  were  used  during  the  operation.  If  necessary, 
animal  inoculation  should  be  resorted  to.  As  a  guide  in  studying  micro- 
organisms, the  following  classification  of  bacteria  {Zapffe's  Bacteriology) 
will  be  useful : — 

First,  as  to  their  shape,  v/e  have  three  principal  divisions  or  groups: 
I.  Micrococci.     II.  Bacilli.     III.  Spirilla. 

I.  The  micrococci  are  spherical  or  slightly  oval  in  shape,  non-motile, 
and  do  not  form  spores.  They  grow  by  binary  division.  This  group  is 
subdivided  further  into  the  following  varieties : 

Diplococcus:  Two  micrococci  remaining  attached  to  each  other,  or  an 
imperfect  division.  They  may  be  absolutely  spherical  or  the  contiguous 
surfaces  may  be  slightly  flattened  or  concave,  the  "biscuit"  coccus  or  '"sem- 
melkokken." 

Tetrad:  A  group  of  four  cocci,  the  result  of  division  in  two  directions. 

Sarcina :  A  packet  or  cube  of  eight  cocci,  the  result  of  division  in  three 
directions.  This  form  resembles  in  appearance  a  bale  of  cotton  or  a  dice. 

Staphylococcus :  The  most  common  form,  in  which  the  cocci  occur  in 
irregular  groups  of  varying  numbers  and  without  definite  arrangement. 
The  name  is  derived  from  the  Greek  and  is  given  to  this  form  because  of 
its  resemblance  to  a  bunch  of  grapes. 

Streptococcus:  Chains  of  cocci.  When  division  occurs  in  only  one  di- 
rection, with  adhesion  or  attachment  of  the  individual  members,  chains  of 
varying  length  are  formed.  Some  authors  distinguish  a  streptococcus  longus 
and  a  streptococcus  brevis — that  is,  long  chain  and  short  chain ;  and  a  few, 
a  streptococcus  conglomeratus.  When  the  chain  is  composed  of  diplococci, 
it  is  called  a  strepto-diplococcus. 

Ascococcus  and  leuconostoc  are  two  very  unusual  groupings  of  cocci. 
In  the  former  the  cocci  are  associated  in  globular  or  lobulated  miasses  held 
together  by  a  firm,  gelatinous,  intracellular  substance.  In  the  second  variety 
the  cocci  grow  in  chains  or  masses,  and  are  surrounded  or  enclosed  by  a 
very  thick  and  tough  gelatinous  capsule. 


PLATE  XIII. 

Diagrammatic  frontal  section  through  the  pelvis,  exposing  the  rec- 
tum (A). 

The  pelvic  diaphragm  (B)  is  seen  passing  from  the  inner  surface  of 
the  true  pelvis  to  the  lower  end  of  the  rectum.  This  diaphragm  is  perforated 
on  one  side  by  the  protrusion  of  a  hernial  sac  which  is  still  situated  within 
the  ischio-rectal  fossa. 

Inferior  Hernia  (Perineal).  A.  Rectum.  B.  Pelvic  diaphragm.  C. 
Parietal  peritoneum.     D.  Sac  of  a  perineal  hernia. 


SURGICAL    BACTERIOLOGY  85 

II.  The  bacilli  are  rod-shaped  or  filamentous  bacteria,  motile  or  non- 
motile,  flag^ellated  or  not,  reproducing  themselves  both  by  fission  and  sporu- 
lation.  They  are  not  subdivided  into  groups,  but  exhibit  considerable  varia- 
tion of  shape.  Some  are  quite  short  and  thick ;  others  are  long  and  slender ; 
some  very  large  and  some  very  small.  They  may  be  so  short  as  to  resemble 
a  coccus,  hence  the  term  oval  coccus.  Some  have  rounded  ends ;  others 
pointed,  squared  or.  slightly  concave  ends.  They  may  be  spindle-shaped, 
rod-shaped,  club-shaped,  or  of  a  Clostridium  shape.  Their  arrangement  is 
in  some  instances  characteristic.  They  may  be  seen  to  lie  singly  or  in  pairs, 
in  parallel  rows  or  in  chains  of  varying  length,  sometimes  interlacing  freely. 
Very  long,  slender,  and  indistinctly  articulated  filamentous  bacilli  are  known 
as  leptothrix ;  when  these  filaments  present  pseudo-branchings,  they  are 
termed  cladothrix. 

III.  The  spirilla  are  curved  or  twisted  rods  of  varying  length,  en- 
dowed with  motility  and  a  peculiar  rotary  movement,  flagellated  and  repro- 
ducing themselves  by  both  fission  and  sporulation..  They  may  be  very  rigid 
or  exceedingly  flexible.  The  short,  slightly  bent  rods  resemble  a  comma 
so  closely  that  they  frequently  are  referred  to  as  "comma"  bacilli  (cholera), 
or  as  a  vibrio  because  of  their  vibratory  motion.  The  extremely  long  and 
flexible  forms  are  called  spirochaeta  (relapsing  fever).  A  spiromonas  is  a 
ribbon-shaped  spirillum.  When  sulphur  granules  are  found  in  the  proto- 
plasm of  the  organism,  it  is  called  an  ophidomonas. 

Several  higher  forms  of  bacteria  also  are  recognized.  They  approach 
the  plant  in  structure  and  method  of  growth.  Among  these  is  the  strep- 
tothrix,  the  only  form  which  is  encountered  in  animal  pathology.  The  strep- 
tothrix  actinoniyces  (ray  fungus)  is  the  type  of  this  class.  The  tubercle 
bacillus  and  the  diphtheria  bacillus  are  included  by  some  authorities  in  this 
class.  The  streptothrix  presents  true  dichotomous  branchings  and  forms 
very  finely  tangled  m.asses.  In  the  course  of  its  growth  many  stages  of  the 
germ  are  seen.  Occasionally  the  filaments  break  up  and  resemble  chains 
of  bacilli  or  cocci,  or  the  free  ends  of  the  filaments  form  club-shaped  masses, 
which  may  be  an  evidence  either  of  degeneration  or  sporulation. 

Depending  on  their  environment  and  habits,  bacteria  are  divided  into 
saprophytes  and  parasites. 

Saprophytes  feed  only  on  dead  organic  matter,  and  usually  are  not 
disease-producing  bacteria,  unless  by  absorption  of  the  poisonous  products 
formed  by  them  from  the  breaking-down  of  proteids.  Parasites  always 
feed  on  living  organic  matter.  An  organism  may,  however,  be  both  para- 
sitic and  saprophytic,  but  a  saprophytic  existence  precludes  parasitism. 

According  to  the  results  of  their  vital  activity,  bacteria  are  pathogenic 
and  non-pathogenic.  A  pathogenic  organism  is  one  which  is  capable  of  pro- 
ducing disease.  A  non-pathogenic  organism  does  not  of  itself  produce  dis- 
ease. Pure  saprophytes  are  always  non-pathogenic  germs;  whereas  para- 
sites are  usually  pathogenic. 

The  terms  ohligative  and  facultative  are  used  to  express  the  absence  or 
presence  of  the  ability  of  accommodation  to  surroundings.  For  example, 
organisms   which   may   be   either   saprophytic  or  parasitic   are    said   to  be 


86  SURGICAL    BACTERIOLOGY 

facultative  (typhoid  and  cholera  bacilli).  Obligative  bacteria  are  those 
which  must  be  either  one  or  the  other;  as,  for  instance,  the  lepra  bacillus, 
which  is  a  strict  or  obligative  parasite. 

According  to  the  products  of  their  metabolism,  bactaria  may  be  clas- 
sified as : 

1.  Aerogenic — gas-producers. 

2.  Zymogenic — fermentative  bacteria. 

3.  Saprogenic — putrefactive  bacteria.^ 

4.  Chromogenic — color-producers. 

5.  Photogenic — phosphorescent  bacteria. 

PYOGENIC  BACTERIA. 

]\Ianv    bacteria    are    responsible    for   the   formation   of   pus,    bvtt   those 
which  are  classed  particularly  as  pus-producing  germs  are  the  following: 

I.  COCCL 

I.     Staphylococcus  pyogenes:  (a)  aureus;  (b)  albus  ;  (c)  citreus. 
Streptococcus  pyogenes. 
^Micrococcus  gonorrhea  (gonococcus). 
Diplococcus  pneumoniae   (pneumococcus). 
Diplococcus  meningitidis   (meningococcus). 

II.  Bacilli. 
Bacillus  pyocyaneus. 
Bacillus  coli  communis. 
Bacillus  typhosus. 
Bacillus  tuberculosis. 
Bacillus  of  Friedlander    (pneumo-bacillus). 

In  connection  with  infection  of  wounds  made  by  the  herniotomist,  it  is 
well  to  direct  attention  for  a  moment  to  those  micro-organisms  which  J. 
Collins  Warren,  of  Boston,  has  named  the  surgical  bacteria,  because  of  the 
frequency  with  which  the  surgeon  has  to  contend  with  them.  First  among 
these  is  the  staphylococcus  pyogenes  aureus,  an  organism  that  is  widely 
distributed  in  nature,  and  is  always  found  on  the  surface  of  the  body,  be- ' 
"neath  the  finger-nails,  in  the  saliva,  in  the  dust  of  the  street,  on  the  floors 
and  walls  of  houses  and  hospitals,  in  the  air  and  in  the  water,  and  wherever 
it  may  have  been  deposited  from  a  previous  infection.  The  staphylococci 
are  about  one  micron  in  diameter  and  have  an  arrangement  resembling  a 
bunch  of  grapes,  from  which  they  derive  their  name.  The  entire  group  of 
staphylococci  grows  readily  on  all  the  various  culture  media  and  at  tem- 
peratures as  low  as  6°  C,  and  as  high  as  44P  C.  The  staphylococcus  is  an 
exceedingly  tenacious  germ,  retaining  its  vitality  for  a  long  time  under  the 
most  adverse  circumstances.  It  is  killed  rapidly  by  exposure  to  live  steam 
and  by  3  per  cent,  solution  of  carbolic  acid.  All  the  staphylococci  cause 
local  suppurative  inflammations,  and  while  they  exhibit  but  little  tendency 
to  spread,  they  occasionally  are  the  cause  of  a  fatal  septicemia  or  pyemia. 
The  aureus  is  the  most  common  and  also  the  most  virulent  of  the  staphylo- 
cocci. The  albus  is  the  least  virulent  variety.  The  citreus  is  very  uncom- 
mon and  is  alwavs  associated  with  the  other  varieties  of  staphylococci.     The 


SURGICAL    BACTERIOLOGY  8/ 

Staphylococcus  epidermis  albus,  which  was  described  by  W^dch,  occurs  con- 
stantly on  the  skin  and  in  its  deeper  layers.  It  is  believed  to  be  an  atten- 
uated form  of  the  albus.  Two  feeble  pathogenic  forms  of  staphylococci 
are  the  staphylococcus  cereiis  albus  and  the  staphylococcus  cereus  flavus. 
They  are  found  on  the  skin  and  in  the  external  auditory  canal.  The  staphy- 
lococcus viridis  Havescens  is  met  with  occasionally.  The  micrococcus  pyo- 
genes tenuis  resembles  the  aureus  slightly,  both  biologically  and  morphologi- 
cally.    It  is  very  uncomm.on. 

The  streptococcus  pyogenes  is  an  exceedingly  virulent  germ,  possessing 
but  little  vegetative  power,  and  is  the  cause  of  almost  all  severe  and  rapidly 
fatal  infective  inflammations.  It  is  of  about  the  same  size  as  the  staphylococ- 
cus, but  always  occurs  in  the  form  of  a  chain,  from  whence  its  name.  The 
germ  has  been  found  in  hospital  wards,  in  operating  rooms,  in  the  mouth, 
nose,  pharynx,  intestinal  canal,  vagina,  urethra,  on  the  skin,  and  in  the  infec- 
tions caused  by  the  germ  itself. 

The  bacillus  pyocyaneus,  though  not  a  pus-producing  germ,  is  fre- 
quently found  in  pus,  to  which  it  imparts  a  blue  or  green  color.  It  has  been 
found  on  the  skin,  especially  in  the  axilla,  in  the  external  auditory  canal, 
and  in  the  intestinal  mucus.     It  grows  very  abundantly  in  culture. 

An  organism  in  the  same  class  with  the  bacillus  pyocyaneus  is  the 
micrococcus  tetragenus,  a  germ  that  occurs  in  squares  of  four  cocci,  grows 
abundantly  in  culture,  and  is  seen  most  frequently  in  specimens  of  tuber- 
culous sputum.  It  is  also  present  in  the  mouth.  It  is  not  believed  to  be 
pathogenic  for  man. 

The  bacillus  pyogenes  fetidus,  which  has  been  found  on  several  occa- 
sions in  the  pus  in  abscesses,  also  belongs  to  this  class. 

The  bacillus  coli  communis,  although  ordinarily  a  non-pyogenic  germ, 
is  not  infrequently  found  in  the  contents  of  abscesses,  especially  in  those 
abscesses  that  occur  in  the  vicinity  of  the  intestinal  tract. 

^lany  other  germs  have  been  found  more  or  less  often  in  the  contents 
of  abscesses,  but  without  being  necessarily  pus-producers  themselves.  Other 
bacteria  with  which  the  surgeon  ma}-  come  in  contact  in  connection  with 
his  operative  work  are  the  streptococcus  erysipelatus,  bacillus  tetanus,  bacil- 
lus tuberculosis,  bacillus  mallei,  lepra  bacillus,  bacillus  of  syphilis,  bacillus 
of  malignant  edema,  bacillus  of  pseudo-edema,  bacillus  anthracis,  bacillus 
acrogenes  capsulatus,  and  the  actinoniyces,  or  ray  fungus. 

Asepsis  and  antisepsis  have  revolutionized  surgery  to  such  an  extent 
that  infection  occurs  very  infrequently.  In  pre-antiseptic  days,  and  during 
the  period  of  time  that  antisepsis  and  asepsis  were  being  developed,  that  is, 
before  our  technic  was  as  perfect  as  it  is  to-day,  wound  infection  was  a 
common  occurrence,  and  any  one  of  the  bacteria  mentioned  above  might 
have  been  the  cause  of  the  infection.  Particular  attention  is  now  paid  to 
these  germs  because  of  this.  !Many  patients  who  would  have  survived  the 
operation  died  from  sepsis.  In  other  instances  the  patient  was  inoculated 
with  the  germ,  such  as  the  bacillus  of  tuberculosis,  the  bacillus  of  anthrax, 
or  the  bacillus  of  leprosy,  which,  though  it  may  not  have  caused  death 
immediately,  produced  severe  systemic  disturbances  from  which  the  patient 


88  SURGICAL    BACTERIOLOGY 

did  not  recover.  Infection  with  the  tetanus  bacillus  was  dreaded  particu- 
larly, and  malignant  edema,  anthracosis  and  local  tuberculosis  have  been 
reported  many  times  as  occurring  after  operations  for  the  cure  of  hernia, 
as  well  as  after  other  operations.  I  have  also  seen  one  case  of  actinomycosis 
caused  by  contamination  of  catgut  which  was  used  during  the  operation. 

The  occasional  operator  is  much  more  likely  to  have  infection  because, 
as  a  rule,  he  is  obliged  to  operate  under  the  most  adverse  conditions.  He 
cannot  choose  his  operating  room,  nor  can  he  choose  the  time  of  operation. 
Most  of  his  work  is  emergency  surgery,  but  if  he  will  be  reasonably  careful 
in  his  technic,  and  allow  nothing  to  come  in  contact  with  the  wound  that 
has  not  been  sterilized,  he  can  avoid  infection  in  the  majority  of  instances. 

The  rarer  varieties  of  infection,  those  in  which  the  bacillus  of  leprosy, 
the  bacillus  of  syphilis,  the  bacillus  of  tetanus,  are  the  causative  germs,  can 
be  ruled  out  entirely.  If  the  operator  has  come  in  contact  with  a  case  of 
erysipelas,  he  should  exercise  more  than  usual  care,  because,  as  has  been 
pointed  out  above,  the  streptococcus  of  erysipelas,  like  all  other  streptococci, 
is  a  very  virulent  organism,  and  it  is  carried  easily  from  one  place  to  another 
on  the  clothing  or  any  substance  that  may  come  in  contact  with  the  patient. 
Wound  infection  with  the  streptococcus  is  very  likely  to  prove  fatal.  There- 
fore, when  an  operation  has  been  arranged  for,  the  surgeon  had  better  not 
visit  any  cases  of  erysipelas  on  that  day. 


CHAPTER  IX. 

INFECTION. 


By  infection  is  meant  the  multiplication  of  certain  microbes  in  wounds 
and  in  the  body,  causing  local  and  constitutional  disturbances  peculiar  to 
them.  When  these  bacteria  enter  a  wound  they  multiply  and  cause  what  is 
termed  a  local  infection.  A  constitutional  infection  is  said  to  occur  when 
the  health  of  the  individual  is  disturbed  by  the  absorption  of  bacteria  and 
their  products  into  the  circulation.  A  blood  infection,  commonly  called 
blood  poisoning,  takes  place  when  the  bacteria  enter  the  circulation  and 
multiply  there.  This  always  produces  grave  constitutional  symptoms.  In- 
fectious diseases  are  those  that  are  communicated  from  one  individual  to 
another  by  the  particular  germs  that  cause  them. 

Infection  may  occur  not  only  with  the  vegetable  organisms  (that  is, 
bacteria,  moulds  and  yeasts),  but  also  with  the  animal  parasites,  such  as 
the  ameba  coli  and  the  malarial  hematozoon. 

Infection  is  often  referred  to  as  being  primary  and  secondary.  It  is 
primary  when  it  occurs  irrespective  of  other  existing  conditions.  The 
infection  of  a  wound  is  always  a  primary  process.  A  secondary  infection  is 
one  that  is  engrafted  on  a  part  of  the  body  that  already  has  suffered  from 
the  ravages  of  another  organism.  A  good  illustration  of  this  is  the  invasion 
of  a  tuberculous  abscess  by  pyogenic  cocci. 

The  infection  may  also  be  local  and  general. 

In  the  condition  known  as  sapremia,  or  septic  intoxication,  the  infection 
is  due  to  the  absorption  into  the  tissues  of  the  ptomaines  produced  by 
saprophytic  bacteria  (putrefactive  bacteria),  which,  while  not  entering  the 
blood  themselves  (i.  e.,  remaining  in  the  focus  of  infection),  yet  produce 
substances  that  are  absorbed  by  the  body  and  enter  into  the  blood  and  lymph 
channels.  The  absorption  of  fibrin  formed  in  a  wound  produces  effects  that 
are  very  similar  to  those  produced  by  the  absorption  of  these  ptomaines. 

By  mixed  infection  is  meant  the  "presence  in  the  tissues  of  more  than 
one  variety  of  organism  at  the  same  time.  This  is  seen  frequently  in 
tuberculosis,  pneumonia,  and  in  wound  infections. 

A  terminal  infection  is  one  occurring  in  an  individual  suffering  from 
some  chronic  organic  disease  and  which  ends  fatally.  One  infection  may 
subside  and  another  take  its  place. 

When  the  poison  is  generated  within  the  body  itself  as  the  result  of 
faulty  metabolism  or  the  inadequate  elimination  of  waste  products  and 
their  subsequent  decomposition,  a  form  of  poisoning  occurs  known  as  auto- 
.  intoxication  or  auto-infection.  Several  interesting  cases  of  blood  infection 
induced  by  latent  infection  becoming  aroused  by  exposure  to  cold  have 
been  observed  by  the  author. 


go  INFECTION 

Before  it  is  proven  that  a  certain  germ  is  the  cause  of  an  infection, 
there  are  a  number  of  conditions  and  requirem.ents  that  must  be  met.  These 
have  been  laid  down  definitely  by  Koch  and  by  Henle,  and  are  known  as 
Koch's  law.  I.  The  micro-organism  must  be  found  in  the  blood  or  lymph  or 
in  the  tissues  of  the  person  infected.  2.  The  germ  must  be  isolated  and  cul- 
tivated. 3.  The  infection  or  disease  under  investigation  must  be  repro- 
duced by  inoculation  of  man  or  animals  with  the  artificially  cultivated  germs. 
4.  The  same  bacterium  must  again  be  found  in  the  tissues,  blood  or  lymph, 
of  the  person  or  animal  inoculated.  When  an  organism  meets  these  require- 
ments, it  is  accepted  as  the  specific  cause  of  the  disease  or  infection  that  is 
being  investigated. 

It  is  important  for  the  operator  to  know  of  the  sources  from  which 
infection  may  come.  The  easiest  way  to  keep  these  in  mind  is  by  remem- 
bering the  few  tissues  and  organs  in  the  body  in  which  germs  do  not  exist 
normally.  Bacteria  are  not  found  in  any  tissues  or  organs  that  have  no 
connection  with  the  skin  or  with  the  mucous  surfaces,  such  as  the  brain, 
spinal  cord,  nerves,  muscles,  bones,  joints,  ligaments,  tendons,  adipose  tissue, 
heart,  blood,  l3aiiph  glands  and  vessels,  lymph,  peritoneal  cavity,  spleen, 
arteries  and  veins,  and  suprarenal  bodies.  There  has  been  considerable  con- 
troversy on  this  subject,  some  investigators  claiming  that  they  found  bacteria 
in  healthy  normal  organs  and  tissues,  but  it  is  now  generally  conceded  that 
these  are  free  from  germs.  Germs  are  not  found  in  normial  secretory 
organs,  such  as  the  salivary  glands  and  their  ducts,  the  liver,  gall-bladder  and 
its  ducts,  pancreas  and  ducts,  kidneys,  ureters  and  bladder,  ovaries,  uterus 
'  and  Fallopian  tubes,  the  mammary  glands  and  their  ducts,  lungs,  testes, 
vas  deferens  and  prostate  gland.  While  germs  are  not  present,  normally,  in 
the  sudoriferous  glands  (the  perspiration  being  germicidal  in  its  action), 
still  the  skin  and  its  appendages,  the  sebaceous  glands  and  hair  follicles,  are 
never  free  from  bacteria. 

SOURCE  OF  WOUND  INFECTION. 

Let  us  now  enumerate  the  chief  sources  of  infection  of  wounds  made 
by  the  surgeon. 

1.  The  Atmosphere.  Bacteria  of  all  kinds,  pathogenic  and  nour 
pathogenic,  are  always  to  be  found  in  the  air.  These  germs  being  heavier 
than  air  are  deposited  on  objects  in  the  operating  room,  on  instruments, 
dressings,  sutures,  as  well  as  on  the  wound  surfaces.  Although  the  danger 
of  infection  from  this  source  is  not  very  great,  yet  the  atmosphere  in  which 
patients  are  operated  and  cared  for  should  be  kept  as  free  from  dust  as 
possible.  Where  there  is  obvious  dirt,  there  is  dust,  and  when  one  can 
see  the  dust  in  the  air,  or  on  articles  of  furniture,  and  other  exposed  objects, 
there  are  sure  to  be  swarms  of  bacteria,  sufficient  to  infect  an  open  wound. 
An  operation  should  not  be  performed  under  such  conditions,  if  it  is  at  all 
possible  to  avoid  it. 

2.  The  Skin  of  the  Patient.  The  skin  of  the  newborn  babe  is  germ 
free  (Nuttall),  but  it  soon  becomes  covered  with  bacteria  which,  when  they 
enter  a  wound,  will  cause  suppuration  and  even  death.     These  germs  find 


PLATE   XR'. 
Femoral  Hernia.     Internal,  Anterior.  External. 


INFECTION  93 

their  way  into  the  various  folds,  crevices  and  appendage?  of  the  skin, 
making  the  task  of  removing  them  mechanically  with  soap,  brush  and 
water  impossible.  Therefore,  the  patient's  skin  ma}-  be  the  source  of  his 
infection. 

Different  varieties  of  germs  are  found  to  inhabit  various  parts  of  the 
skin  and  they  often  produce  infectious  skin  diseases  that  are  peculiar  to 
these  parts.  The  skin  of  the  pubis  and  of  the  groin  is  heavily  laden  with 
germs.  The  staphylococcus  epidermis  alhus  is  always  present  everywhere 
on  the  skin.  It  is  not  pathogenic,  but  will  cause  pus.  The  odor  of  sweating 
feet  is  caused  by  the  bacillus  graveolens,  also  non-pathogenic.  The  red 
sweat  of  some  individuals  is  caused  by  the  bacillus  prodigiosiis  (non-patho- 
genic). 

3.  The  Skin  of  the  Hands  of  the  operator  and  of  his  assistants,  espe- 
cially beneath  the  nails,  is  never  free  from  bacteria  and  is  probably  the 
greatest  source  of  infection  in  hernial  operations  when  these  are  performed 
with  bare  hands,  that  is  without  rubber  gloves.  Xo  one  should  operate  or 
assist  who  has  an  obvious  infection  of  the  hands,  such  as  eczema  or  suppurat- 
ing wounds.  Internes  and  assistants  coming  in  contact  with  suppurating 
cases  must  take  every  care  not  to  touch  pus.  Xurses  should  not  be  in  the 
operating  room  during  menstruation,  or  while  suffering  from  vaginal  dis- 
charges, because  under  those  conditions  it  is  rather  difficult  for  them  to  se- 
cure "surgical  cleanliness"  of  their  hands. 

4.  Water.  There  are  too  m.any  bacteria  present  in  ordinary  tap  water 
to  use  it  with  impunity  at  operations,  except  for  the  primary  scrubbing  of 
the  hands.  If  even  a  trace  of  organic  matter  is  found  in  it,  bacteria  are 
always  present,  but  water  free  from  organic  matter  may  contain  live  germs. 
•■'Ordinary  hydrant  water  usually  contains  from  two  to  fifty  bacteria  per 
cubic  centimeter  ;  filtered  river  water  from  fifty  to  two  hundred ;  unfiltered 
river  water  from  6,000  to  20.000 ;  ground  water  may  contain  as  many  as 
130,000"  (Zapffe). 

The  bacteria  in  water  are  usually  of  the  non-pathogenic  variety.  The 
two  most  important  pathogenic  organisms  are  the  typhoid  and  the  cholera 
bacillus.  The  bacillus  coli  comnnmis  is  found  in  water  into  which  sewage 
empties.  The  water  obtained  from  deep  artesian  wells  is  free  from  germs. 
Water  from  lakes  and  rivers  is  septic.  Even  distilled  water  may  contain 
germs.  For  surgical  purposes  the  water  must  be  sterilized,  rendered  free 
from  pathogenic  microbes,  and  kept  in  bulk,  both  hot  and  cold.  While 
boiling  is  simple  and  efficient,  it  is  a  laborious  process  to  cool  and  properly 
retain  water  that  is  fit  for  all  practical  purposes.  A  special  water  sterilizer 
should  be  installed  in  every  hospital  operating  room. 

Instruments  and  Materials  Used  at  the  Operation.  These  constitute 
a  frequent  source  of  infection  when  not  rendered  aseptic. 

An   aseptic   scalpel  becomes   septic   upon   severing  the   skin   when   its 

■  follicles  are  crowded  with  bacteria.     This  scalpel  should  not  be  used  again 

during  the  operation  without  being  disinfected  in  carbolic  acid  and  alcohol, 

for  fear  of  carrying  the  bacteria  into  the  deeper  structures,  and  thus  infect- 

ins-  them.    I  am  indebted  to  Flovd  W.  McRae,  of  Atlanta,  Georgia,  for  this 


94  INFECTION 

bit  of  surgical  technic.  It  is  not  only  a  good  plan  to  discard  the  scalpel,  but 
also  to  antisepticize  the  edges  of  the  skin  wound  with  some  efificient  anti- 
septic solution.  The  most  efficient  solution  is  Harrington's,  but  it  must 
be  used  sparingly  by  gentle  mopping;  in  fact,  one  sweep  with  a  pledget  of 
gauze  moistened  in  it  is  sufficient. 

2.  Catgut  is  a  source  of  infection,  and  it  must  be  rendered  aseptic 
before  using.  (See  Chapter  XII.)  When  aseptic  catgut  is  used  to  check 
hemorrhage  and  to  coapt  the  deep  structures  in  hernial  operations  (or  in 
operations  for  other  conditions),  it  may  become  infected  in  the  application 
of  such  ligatures  and  sutures.  It  is  during  the  operation  that  the  germs 
are  accidentally  introduced,  and  hence  Kocher  calls  this  "implantation  in- 
fection" {Operative  Surgery,  Trans.  IV  Ed.,  p.  33),  and  urges  the  use  of 
antiseptic  material  for  buried  sutures  and  ligatures  instead  of  that  which  is 
merely  aseptic. 

3.  The  manner  of  using  the  needles  is  sometimes  a  source  of  infection. 
When  a  cutting  needle  is  passed  from  without  inward  and  strikes  a  nest 
of  germs  in  the  hair  follicles  and  sebaceous  glands,  they  are  undoubtedly 
carried  by  the  needle  and  suture  to  sterile  tissues.  It  depends  upon  the 
number,  nature  and  activity  of  those  germs  whether  suppuration  follows  or 
not.  The  late  G.  R.  Fowler,  of  Brooklyn,  N.  Y.,  is  credited  with  this 
observation. 

4.  The  author  holds  the  same  objection  to  the  subeuticular  suture, 
because  the  needle  and  suture  must  pass  through  the  deep  skin  where  hair 
follicles,  sebaceous  and  sweat  glands  abound  and  may  be  harboring  pyogenic 
bacteria. 

5.  Suturing  the  skin  too  tightly  is  a  frequent  source  of  stitch  abscess 
in  the  hands  of  many  operators,  by  causing  necrosis  of  the  skin  where  the 
stitch  is  applied. 

6.  Rough  Handling.  When  an  operator  lowers  the  vitality  of  the 
tissues  by  tearing,  bruising,  undue  clamping,  using  too  many  ligatures,  etc., 
a  predisposition  to  infection  is  created.  Infection  supposed  to  have  been 
caused  by  such  rough  handling  of  the  structures  has  been  called  "lesion 
infection"  by  Travel,  and  "necrosis  infection"  by  Kocher. 

7.  Contact  infection  is  a  great  source  of  inflammation,  suppuration 
and  all  infective  diseases,  from  water,  the  skin  of  patient,  hands  of  the 
operator,  the  instruments,  solutions,  vessels,  sponges,  ligatures,  sutures, 
drainage  tubes,  dressing  materials,  and  the  mode  of  their  application,  drops 
of  perspiration,  dust  and  dandruff  from  the  hair,  mucus  droplets  from  the 
mouth  when  talking,  coughing,  etc.,  the  clothing  of  operator,  his  assistants 
and  nurses,  eye-glasses  or  spectacles,  insects,  visitors,  etc.,  etc. 

8.  Breath  Infection.  The  expired  air  is  sterile  (Tyndall),  conse- 
quently the  more  respiration  that  goes  on  in  a  room,  the  greater  the  decrease 
in  the  number  of  bacteria  in  it,  even  when  the  room  becomes  stuffy.  It 
has  also  been  proven  that  micro-organisms  are  not  given  off'  from  moist 
surfaces.  The  exhaled  air  does  not  carry  with  it  the  germs  so  numerous 
along  the  respiratory  tract.  From  these  two  facts,  (a)  that  the  exhaled 
breath  is  sterile,  and  (b)  that  germs  are  not  given  off  from  moist  surfaces 


PLATE  XV. 
Consrested — 2  hours. 


INFECTION  97 

(Schimmelbusch),  one  can  justl}^  say  that  the  surgeon,  his  assistants  and 
nurses,  and  visitors  cannot  by  the  act  of  respiration  infect  a  wound.  There 
is,  however,  a  breath  infection,  and  that  is  from  speaking,  coughing,  laugh- 
ing, and  sneezing,  during  which  efforts  it  has  often  been  proven  that  drops 
of  mucus  and  saHva  fly  from  the  mouth,  and  particles  of  the  secretions  of 
the  Schneiderian  membrane  come  from  the  nose,  all  laden  with  non-patho- 
genic, pyogenic  and  pathogenic  bacteria.  No  one  who  is  suffering  with  a 
cough  should  operate  or  assist  at  an  operation. 

9.  Infected  Wounds.  The  discharges  from  infected  wounds  carried 
in  various  ways  to  clean  wounds  were  at  one  time  the  most  common  sources 
of  infection.  Anyone  dressing  septic  wounds,  by  the  careful  use  of  his 
hands,  with  or  without  gloves;  by  using  dressing  forceps,  scissors,  or  other 
instruments,  as  the  case  may  require ;  and  by  the  complete  sterilization  of 
these  instruments  before  and  after  using,  should  be  able  to  reduce  this 
source  of  infection  to  practically  nothing. 

10.  Excreta,  Urine  and  Feces.  In  hernia  operations  on  children  it  is 
important  to  protect  the  wound  against  contamination  with  urine  or  feces. 
This  may  be  done  in  several  ways.  A  collodion  dressing  may  be  applied, 
but  it  may  cause  irritation  of  the  tender  young  skin.  A  double  dressing 
with  rubber  or  oiled  silk  between,  properly  bandaged,  affords  a  safe  protec- 
tion against  infection  from  this  source.  The  outer  dressing  can  be  changed 
whenever  it  is  soiled  without  endangering  the  wound. 

Obscure  Sources.  Inasmuch  as  there  is  no  method  of  surgical  technic 
that  is  absolutely  proof  against  sepsis,  we  must  not  be  over-sanguine  in  our 
powers,  individual  or  combined,  to  always  prevent  infection  of  the  wounds 
we  make  ourselves.  Experience  has  taught  that  there  is  no  known  standard 
of  the  resisting  powers  of  any  person  against  the  invasion  of  living  germs. 
It  is  sometimes  in  the  stalwart  and  robust  that  pyogenic  germs  find  a  suit- 
able nidus  for  their  multiplication,  while  the  weakling  is  not  assailed.  In 
such  a  case  the  sepsis  cannot  be  attributed  to  a  "lowered  vitality  of  the  tis- 
sues." 

There  are  some  cases  of  infection  caused  by  conditions  which  the  oper- 
ator appears  to  have  no  power  to  prevent.  It  may  be  in  the  fluids  and  tis- 
sues of  the  patient,  or  it  may  be  the  virulence  of  the  germs  in  certain  known 
conditions  that  when  once  introduced  into  the  wound  they  cause  acute 
Inflammation,  which,  in  turn,  may  cause  septicemia  and  pyemia,  as  well  as 
local  suppuration.  The  surgeon  has  no  control  over  the  nature,  number  and 
virulency  of  germs  that  enter  the  blood  by  inhalation,  ingestion,  absorp- 
tion from  an  infection  elsewhere,  or  of  the  bacteria  conveyed  by  insects  and 
sometimes  vermin.  Nature  is  wondrous  kind  in  disposing  of  even  a  marked 
constitutional  infection  from  these  sources  without  any  interference  with 
the  healing  of  a  hernial  wound. 

The  egress  of  germs  from  the  system  is  by  the  emunctories,  the  feces, 
urine,  breath  and  perspiration,  and  many  of  the  micro-organisms  are  ex- 
terminated by  the  living  blood  and  tissues  of  the  body.  When  local  sup- 
puration takes  place  in  a  wound,  bacteria  are  eliminated  with  the  purulent 
discharges. 


98  INFECTION 

PREDISPOSITION  TO  INFECTION. 

This  is  both  hereditary  and  acquired.  It  is  well-known  that  some  per- 
sons are  more  easily  infected,  locally  and  constitutionally,  than  others. 
There  is  a  personality  that  predisposes  to  infection  which  is  handed  down 
from  posterity,  though  not  all  the  members  of  a  family  may  show  it.  The 
person  so  constituted  has  no  natural  immunity  or  innate  power  to  resist  in- 
fections of  some  kind.  It  is  strange  that  through  animate  creation  one  in- 
dividual resists  certain  diseases  and  infections,  and  falls  an  easy  victim  to 
others.  The  negro  does  not  easily  take  yellow  fever,  but  smallpox  or 
tuberculosis  very  swiftly  overcome  him. 

The  age  of  a  person,  which  bears  so  clearly  on  the  invasion  of  conta- 
gious and  infectious  diseases  as  to  justify  us  in  making  a  classification  on 
this  basis,  viz.,  diseases  peculiar  to  children,  adults  and  to  old  people,  has 
also  a  distinct  bearing  on  the  predisposition  to  infections  of  wounds  after 
operations.  It  is  noticeable  that  in  young  children  and  old  people  wounds 
heal  with  but  comparatively  little  tendency  to  infection.  In  the  case  of  the 
aged  they  possess  thin  skins,  slow  phagocytes,  and  feeble  tissues.  There 
appears  to  be  a  lack  of  something  in  the  wound  and  tissues  of  a  vigorous 
adult  that  is  present  in  the  wound  of  a  child  or  an  old  man  that  predisposes 
to  infection.  This  practical  observation  is  not  certainly  explained  by  the 
"theory  of  phagocytosis",  by  Metchnikoff.  It  may  be,  however,  that  the 
tissues  of  the  very  young  and  the  very  old  are  more  blessed,  than  those  of 
the  adult,  with  active  germicidal  properties  in  the  form  of  alexins  or  pro- 
tective albumins. 

Although  great  progress  has  been  made  towards  finding  out  the  cause 
of  natural  immunity,  it  is  still  manifest  that  its  phenomena  are  not  wholly 
explained  by  either  (nor  by  the  combination)  of  the  two  theories  now  pre- 
vailing, viz.,  the  (a)   "phagocytic",  and   (b)   "humoral." 

The  observations  of  Metchnikoff  are  accepted  as  correct  as  far  as  they 
go.  There  appears  to  be  no  doubt  that  the  phagocytes  are  the  scavengers 
that  materially  clean  up  an  infected  wound.     He  proved  that 

1.  Certain  cells  (wandering  phagocytes — mono — and  polymorphonu- 
clear white  cells  and  connective  tissue  cells)  first  enclose,  then  digest,  anri 
eventually  remove  infective  bacteria  from  the  body. 

2.  Cells  destroy  germs  in  all  forms  of  infection,  and  particularly  in 
those  instances  tending  to  recovery. 

3.  Numerous  leucocytes,  either 

(a)  Migrate  towards  the  infected  part  (positive  chemiotaxis),  or 

(b)  May  avoid  the  infected  area   (negative  chemiotaxis). 

The  cells  are  attracted  by  certain  toxins  and  repelled  by  toxins  of  many 
virulent  micro-organisms. 

It  has  also  been  demonstrated  that  the  fluids  of  the  body  have  germi- 
cidal powers.  Especially  is  this  a  property  of  blood  serum.  The  fluids  that 
manifest  bactericidal  properties  have  been  named  alexins  or  protective  al- 
bumins. It  is  claimed  also  that  the  alexins  are  derived  chiefly  from  leu- 
cocytes.    There    is   no    doubt    but    that    one    attack    of    inflammation    pre- 


INFECTION  "  99 

disposes  to  another.  There  are  a  great  many  conditions  which  we  cannot 
enter  into  here,  as  well  as  certain  diseases,  such  as  diabetes  and  scur\ry-,  that 
render  the  tissues  of  the  body  weakened  in  vitality  and  predispose  to  in- 
fection. 


CHAPTER  X. 

STERILIZATION  AND  DISINFECTION. 

Because  of  the  ubiquitous  presence  of  bacteria  in  the  air  and  in  rooms, 
on  articles  of  furniture  and  on  tlie  skin  of  the  body,  etc.,  and  also  because 
of  the  dangers  consequent  upon  these  bacteria  entering  wounds,  a  very  im- 
portant part  of  bacteriologic  technic  on  the  part  of  the  surgeon  consists  in 
destroying  these  micro-organisms  by  sterilization  and  disinfection. 

Sterilization  is  accomplished  either  by  heat,  filtration,  or  the  action  of 
chemicals.  Usually  the  term  sterilization  is  intended  to  imply  destruction 
of  bacteria  by  heat.  Disinfection  means  the  destruction  of  bacteria  by  the 
use  of  chemicals.  Any  substance  which  is  capable  of  killing  bacteria  is 
called  a  germicide.  One  w^hich  inhibits  the  development  of  bacteria  is 
called  an  antiseptic.  An  object  is  said  to  be  sterile  when  it  is  entirely  free 
fro::i  bacteria  and  their  spores.  An  object  is  septic  when  it  contains  actively 
growing  bacteria  or  their  poisonous  products.  Aseptic  is  synonymous  with 
sterile. 

All  bacteria  have  a  thermal  death-point,  and  the  method  of  steriUz- 
ing  and  time  of  exposure  are  regulated  accordingly.  Culture  media,  tluids, 
and  anything  that  can  be  subjected  to  it  are  sterilized  by  some  form  of  heat. 

Sterilization  by  Heat.  This  is  accomplished  by  fire ;  dry  heat  or  hot 
air;  live  steam;  superheated  steam,  or  steam  under  pressure;  and  boiHng. 

Fire.  Sterilization  by  the  actual  flame  is  absolutely  certain  in  its  re- 
sults, because  it  completely  destroys  all  infected  matter.  Naturally  that 
would  limit  its  use  considerably,  but  it  is  useful  in  surgical  cases  in  or  out 
of  the  hospital  when  delay  is  an  element  of  danger  to  the  patient. 

Steel  instruments,  knives,  needles  and  hypodermic  needle,  should  not  be 
held  in  the  flame  for  any  length  of  time,  as  it  affects  the  temper  of  the  metal. 
They  can  be  passed  through  the  flame  a  few  times  and  then  used. 

When  a  surgeon  is  so  placed  that  surgical  dressings  are  not  available, 
he  can  improvise  sterile  dressings  by  the  use  of  fire.  Cotton  or  linen  fab- 
rics (woolen,  even  straw  or  moss)  may  be  burned  and  scorched,  the  burnt 
material  to  be  applied  next  the  wound,  and  that  w^hich  is  scorched  as  an 
external  dressing.  The  author  secured  primary  union  of  an  amputation 
below  the  knee  under  a  dressing  prepared  by  fire,  as  above  mentioned,  two 
pillow  slips  and  a  sheet  being  utilized  for  that  purpose. 

Dry  Heat.  This  also  has  a  very  limited  application;  a  very  high  tem- 
perature is  required,  150°  C,  and  an  exposure  of  at  least  one  hour.  This 
wall  kill  all  known  bacteria  and  their  spores.  Its  application  is  limited  to 
the  sterilization  of  glassware  used  in  the  operating  room  and  in  the  labora- 
tory. Articles  made  of  rubber,  wood,  or  crockery  cannot  be  sterilized  by 
drv  heat. 


STERILIZATION    AND   DISINFECTION  IQl 

The  hot-air  chamber  is  a  single  or  double-walled  sheet-iron  or  copper 
chest,  having  a  door  on  one  side  and  several  removable  shelves  on  the  in- 
side. The  top  of  the  chest  is  perforated  by  two  holes,  in  one  of  which  is 
placed  a  thermometer  to  indicate  the  inside  temperature.  The  other  open- 
ing is  plugged  with  cotton.  A  large  Bunsen  burner  is  placed  under  this 
chest,  which  rests  on  an  iron  frame.  In  order  to  distribute  the  heat  evenlv, 
a  piece  of  wire  gauze  is 'placed  over  the  burner. 

The  articles  to  be  sterilized  are  placed  on  the  shelves  wnthin  the  cham- 
ber, but  not  until  the  temperature  has  reached  150°  C,  so  that  they  will  re- 
main in  the  chest  exposed  to  that  temperature  for  one  hour.  Frequently  the 
mistake  is  made  of  counting  the  time  from  when  the  tubes,  etc..  are  placed 
in  the  chamber  while  it  is  still  cold. 

Steam.  All  woolen  and  cotton  fabrics,  gauze,  and  wood  must  be  ster- 
ilized by  steam.  Steam  is  very  penetrating,  and  is,  therefore,  a  most  elTec- 
tive  sterilizing  agent. 

The  Arnold  steam  sterilizer,  or  one  patterned  after  it,  may  be  used  for 
this  purpose.  It  is  simple  in  construction,  easily  employed,  and  inexpensive. 
An  exposure  of  one  hour  to  100*^  C.  (212*^  F.)  is  sufficient  to  destroy  bacteria, 
but  bacteria  which  are  in  the  resting-spore  stage  may  resist  the  action  of 
steam  for  hours. 

As  such  a  prolonged  steaming  would  be  impracticable,  the  intermittent 
or  fractional  method  of  sterilizing  is  used.  The  dressings,  gauze,  etc.,  are 
exposed  to  the  action  of  the  steam  for  thirty  minutes  on  each  of  three  suc- 
cessive days.  The  first  sterilization  will  kill  all  the  fully  developed  bac- 
teria. Any  spores  which  may  have  survived  this  sterilization  will  develop 
into  bacteria  in  the  course  of  the  succeeding  twenty-four  hours,  and  these 
are  killed  by  the  next  sterilization.  After  the  third  sterilization  the  ma- 
terials can  safely  be  said  to  be  absolutely  sterile. 

Steam  is  available  for  sterilization  in  four  conditions:  (a)  Plain  steam 
or  steam  in  equilibrium;  (b)  steam  in  active  motion,  called  live  steam;  (c) 
steam  under  pressure — high  tension  steam;  and  (d)  superheated  steam. 
When  steam  (100*^  C.)  is  passed  through  over-heated  tubes  or  chambers 
and  its  temperature  is  raised  above  100°  C,  it  is  said  to  be  superheated. 
This  condition  of  steam  is  not  very  practicable  for  surgical  purposes.  When 
steam  is  used  under  pressure  (high  tension)  in  an  autoclave,  it  is  the  most 
powerful  and  practical  agent  at  our  command  to  sterilize  surgical  dressings, 
etc.,  in  hospitals.  It  is  a  more  potent  germicide  than  live  steam,  and  live 
steam  kills  anthrax  spores  in  less  than  fifteen  minutes. 

Sterilization  by  steam  may  also  be  efl:ected  by  exposing  the  article  to 
be  sterilized  to  the  action  of  streaming  or  live  steam  for  one  hour,  or  for 
thirty  minutes  to  the  action  of  steam  under  a  pressure  of  fifteen  pounds  in 
the  autoclave,  which  is  sufficient  to  destroy  the  spores.  The  dressings  are 
placed  in  the  autoclave  loosely,  the  top  is  screwed  down  firmly,  and  the 
escape  valve  left  open  until  the  steam  has  displaced  the  hot  air.  The 
valve  is  then  closed  and  steam  is  generated  for  thirty  mmutes,  or  longer, 
if  desired.     Cooling  niust  be  allowed  to  take  place  gradually. 


I02  STERILIZATION    AND  DISINFECTION 

DISINFECTION  OF  INSTRUMENTS  AND  MATERIALS  USED  IN  THE  OPER- 
ATING ROOM. 

Great  care  must  be  observed  in  the  operating  room.  Everything 
should  be  absohitely  sterile.  Any  instrument,  towel,  sponge,  or  ligature 
that  falls  to  the  floor  or  comes  in  contact  with  any  unsterilized  object  should 
be  removed  at  once  and  re-sterilized  before  it  is  again  used. 

Instruments  may  be  sterilized  by  dry  heat ;  but  it  is  preferable  to 
subject  them  to  steam  or  to  boil  them  in  a  one  or  two  per  cent,  solution  of 
sodium  bicarbonate,  which  prevents  rusting  and  does  not  dull  the  edge 
of  sharp  instruments.  They  can  either  be  placed  directly  in  the  water  or 
wrapped  in  towels  or  pieces  of  gauze.  As  soon  as  they  are  removed  from 
the  sterilizer  they  are  immersed  in  sterilized  or  distilled  cold  water. 

Boiling  water,  at  lOo"  C.  (212"  F.),  kills  all  forms  of  cocci 
in  at  least  fifteen  seconds,  and  anthrax  spores  m  two  minutes.  The 
boiling  point  of  water  varies  with  altitude,  and  this  must  be  considered  in 
using  boiling  water  for  sterilization  in  high  altitudes,  for  pressure  to  raise 
the  temperature  to  100°  C.  must  be  used,  or  the  addition  of  sodium 
carbonate  (one  per  cent.)  to  boiling  water  at  100"  C.  raises  the 
temperature  to  104"  C,  and  increases  its  germicidal  power,  which 
effects  sterilization  in  high  altitudes.  Boiling  soda  water  is  a  convenient 
agent  for  sterilizing  surgical  instruments,  suture  and  ligature  material, 
but  it  may  also  be  employed  to  sterilize  towels,  sheets,  gauze  sponges,  dress- 
ings, gloves,  caps  and  gowns.  In  the  preparation  for  operations  in  homes 
and  in  the  country,  what  I  should  call  the  kitchen  method  of  sterilisation 
is  safe  and  efficient.  It  makes  a  profound  impression  upon  the  relatives 
and  the  friends  of  the  patient  to  be  operated  upon  to  receive  a  demonstra- 
tion for  three  days  by  the  nurses  of  the  sacred  duties  and  responsibilities 
of  nurses  in  safeguarding  some  of  the  portals  of  danger  to  the  person  com- 
pelled to  go  under  the  knife.  We  should  on  every  available  opportunity 
educate  the  people  regarding  the  importance  of  scientific  surgical  work. 

CHEMICAL  DISINFECTANTS. 

In  the  form  and  strength  in  which  chemical  disinfectants  can  be  put 
to  surgical  purposes  they  are  not  to  be  compared  with  boiling  water  and 
steam  for  efficient  and  safe  disinfection  of  inanimate  materials.  While 
they  are  valuable  in  the  preparation  of  rooms,  some  kinds  of  instru- 
ments, certain  suture  and  ligature  materials,  for  disinfecting  the  hands 
and  wounds,  still  they  are  not  the  best  means  of  disinfecting  dressings, 
bandages,  gauze  sponges,  towels  , sheets,  gowns,  etc.,  in  everyday  use  by 
the  surgeon.  In  this  connection  the  reader  is  referred  to  the  chapter  on 
"Antiseptics  and  Disinfectants." 

The  chemical  disinfectants  may  be  used  either  in  a  gaseous  state  or 
in  solution.  The  best  gases  are  nitric  oxide,  chlorine,  sulphur  dioxide  and 
formic  aldehyde  vapor.  The  best  of  these  is  the  last  mentioned.  Both 
nitrous  fumes  and  chlorine  have  many  practical  disadvantages  and  objec- 
tions which  I  need  not  mention.  If  sulphur  dioxide  is  used,  the  room  should 
be  thoroughly  moistened  and   about  4  pounds  of  sulphur  burned  to  every 


PLATE   XA'I. 

Conafested — a   clavs. 


STERILIZATIOX    AXD   DISIXFECTIOX  IO5 

100  cubic  feet  of  space.  The  formic  aldehyde  vapor  is  the  most  trustworthy 
known  and  its  method  of  utilization  has  already  been  described. 

Formaldehyde. — One  of  the  most  active  disinfectants  and  germicides 
is  formaldehyde.  It  is  obtained  in  the  market  under  the  trade  name  of 
formalin  or  formalose,  a  40  per  cent,  aqueous  solution  of  the  gas  formalde- 
hyde. The  gas  is  extremely  penetrating,  and  is  very  irritating  to  the 
mucous  membranes.  This  limits  its  use  to  the  disinfection  of  inanimate 
objects.  A  15  per  cent,  solution  at  150°  C.  kills  anthrax  spores  in 
one  and  a  half  hours.  Used  as  a  liquid  it  does  not  possess  any  advantages 
over  carbolic  acid  and  similar  preparations.  W'hen  vaporized,  it  is  vastly 
superior  to  all  other  agents.  Robinson,  of  England,  found  that  it  will 
penetrate  a  mattress  and  kill  test  tube  cultures  placed  within  it.  The  gas 
is  generated  rapidly  and  continuously  by  any  of  the  different  styles  of 
formalin  generators  on  the  market.  It  is  used  in  the  form  of  a  spray ; 
or  sheets  saturated  with  formaldehyde  solution  are  hung  up  in  the  tightly 
closed  room  for  twelve  hours,  after  which  the  doors  and  windows  are 
throv^n  wide  open  and  the  room  thoroughly  aired.  The  number  of  sheets 
required  will  depend  on  the  size  of  the  room.  In  a  room  10x10  feet  two 
■sheets  will  suffice.  All  crevices,  keyholes,  etc.,  should  be  packed  with  cotton, 
so  that  none  of  the  vapor  will  escape. 

Novy's  and  the  "Central"  formaldehyde  generator,  and  Schering's 
lamp,  are  exceedingly  simple  in  construction  and  inexpensive.  Others,  like 
Trillat's  autoclave,  are  complicated  and  expensive  Either  the  apparatus  is 
placed  in  the  room,  or  the  vapor  is  sent  in  through  the  keyhole  by  means  of 
a  supply  tube.  The  temperature  of  the  room  should  be  about  21" 
C,  and  it  should  contain  sufficient  moisture 

Sulphate  of  copper  is  an  excellent  and  at  the  same  time  a  very  cheap 
'disinfectant.  It  is  not  irritating  in  one  per  cent,  solution,  and  has  no  odor. 
It  is  especially  valuable  for  the  disinfection  of  typhoid  stools.  A  pound  of 
the  sulphate  is  dissolved  in  2^  gallons  of  w^ater,  and  a  pint  of  this  solution 
is  kept  constantly  in  the  vessel  which  receives  the  discharges  from  both 
bowels  and  bladder.  The  poison  is  destroyed  in  fifteen  minutes  if  the  in- 
fected material  is  mixed  thoroughly  w4th  the  solution. 

In  cases  of  strangulated  hernia  occurring  away  from  hospitals,  where 
no  antiseptics  are  available  but  "blue  stone,''  after  cleansing  the  operative 
area  and  hands  with  soap  and  water,  the  solid  sulphate  of  copper  may  1)e 
■efficiently  used  to  disinfect  the  skin  of  the  patient  and  the  hands  of  the 
•operator. 

Harrington's  Solution. — In  this  connection,  the  following  excerpt  from 
an  article  by  Charles  Harrington  of  Boston  {Annals  of  Surgery,  October, 
1904)  is  of  interest.    He  says  : 

"After  thorough  brushing  with  hot  soapsuds,  what  agent  can  be  relied 
on  to  kill  the  bacteria  that  have  not  been  removed  ?  Not  corrosive  sublimate 
i-iooo,  if  w^e  soak  the  hands  a  quarter  of  an  hour;  not  creolin,  1-20,  if  we 
5oak  them  much  longer;  not  lysol,  nor  solveol,  nor  bacillol,  nor  sulpho- 
naphthol ;  not  peroxide  of  hydrogen ;  not  sublamin  ;  not  mercuric  cyanide  ; 
not  even  formaldehyde  in  5  per  cent,  solution,  even  though  the  skin  could 


TOO 


STERILIZATION    AND  DISINFECTION 


stand  it.  All  of  these  agents  and  several  others  1  have  tested  under  the 
most  favorable  conditions  against  the  common  pus  organisms  and  all  failed 
to  kill  within  reasonable  periods.  A  little  more  than  a  year  ago  I  pub- 
lished the  results  of  a  series  of  experiments  which  demonstrated,  among 
other  things,  that  corrosive  sublimate,  i-iooo,  requires  more  than  ten 
minutes"  contact  to  kill  staphylococcus  albus,  and  that  weaker  solutions 
(1-5000)  act  far  more  slowly.  Recently  I  tried  1-500,  which  solution  is  too 
strong  and  irritating  for  general  application,  and  fovuid  that  it  would  kill 
staphylococcus  aureus  in  from  sixty  to  ninety  seconds  and  the  other  pyo- 
genic organisms  in  from  forty  to  sixty  seconds.  With  i — 100,  I  found  that 
the  aureus  was  killed  after  twenty  seconds.  Now,  if  i — 100  cannot  destroy 
pus  cocci  in  twenty  seconds,  and  i — 500  can  do  so  only  after  a  minute,  and 
i-iooo  only  after  ten  minutes,  what  measure  of  disinfection  does  the  sur- 
geon attain  who  merely  dips  his  hands  into  the  solutions  of  corrosive  sub- 
limate in  common  use  for  only  a  few  seconds  and  then  rinses  them  off 
with  sterile  water  or  salt  solution? 

"The  following  table  shows  the  number  of  minutes  that  the  organism 
employed  remained  in  contact  with  the  several  disinfectants  without  injury, 
and  also  the  shortest  exposure  observed  that  was  sufhcient  for  its  destruc- 
tion : 

Failed  to  Kill.     Killed. 
Agent.  Strength.    (Minutes.)    (Minutes.) 

Carbolic   acid    .n 1-40  3  4 

Carbolic   acid    1-20  i  2 

Trikresol    1-40  2  3 

Trikresol    1-20  i  2 

Lysol    1-40  7  10 

Lysol    1-20  2  3 

Solveol    1-40  10  15 

Solveol   1-20  10  15 

Bacillol    1-40  4  5 

Bacillol 1-20  3  4 

Creolin   1-40  10  15 

Creolin 1-20  10  ■  15 

Sulphonaphtol    1-20  30  45 

Hydrogen  peroxide   Full  strength  4  5 

Formaldehyde    i  per  cent.  60  .  . 

Formaldehyde    2  per  cent.  30  45 

Formaldehyde    3  per  cent.  25  30 

Formaldehyde    5  per  cent.  15  20 

Mercuric  cyanide   i-iooo  180 

Sublamin   i-iooo  10 

Potassium   permanganate    Saturated  10  15 

Potassium  permanganate  and  hydro- 
chloric acid  ( Andre wes)    i  per  cent,  each  4  5 

"My  next  endeavor  w^as  to  find  some  preparation  that  will  kill  not  in 
minutes,   but   in    seconds.      First,    I    experimented   with   a   mixture    which 


STERILIZATION    AND   DISINFECTION  lO/ 

would  kill  staphylococcus  aureus,  albus,  and.  citreus  and  bacillus  p\oc\aneus 
in  less  than  ten  seconds.  Then  I  tried  weakening-  it,  first  as  to  one,  then 
as  to  another  ingredient,  but  always  aiming  to  keep  its  limit  of  required 
time  at  about  ten  seconds.  The  ninth  combination  tried  appeared  to  be  as 
weak  with  respect'  to  each  of  the  active  constituents  as  could  be  made, 
retaining-  that  degree  of  efficiency — that  is,  to  kill  the  pyogenic  bacteria  on 
silk  threads,  not  in  the  skin — v.dthin  ten  seconds.  I  tried  it  against  pus 
from  a  carbuncle  and  against  two  other  specimens  of  uncertain  origin, 
and  at  the  same  time  I  tried  carbolic  acid  and  trikresol,  which  had  proved 
to  be  the  quickest  in  action  of  the  twenty-two  solutions  above  mendoned. 

"The  carbuncle  pus  was  killed  by  trikresol  (1-40)  in  five  and  a  half 
minutes  and  by  carbolic  acid  (1-40)  in  four;  my  mixture  kihed  it  in  less 
than  a  minute,  though  not  in  thirty  seconds.  The  other  specimens  of  pus 
were  both  killed  by  trikresol  and  carbolic  in  two  minutes,  and  by  my  mix- 
ture in  less  than  thirty  seconds. 

"I  have  repeatedly  soaked  my  hand  (without  any  preliminarv  scrub- 
bing) for  two  minutes,  and  then  have  had  plantings  made  from  material 
removed  from  about  each  nail  and  from  scrapings  from  the  skin  of  each 
finger  and  from  the  palm.  Occasionally,  I  got  a  growth ;  but,  as  a  rule, 
every  tube  of  bouillon  remained  clean  and  sterile.  A  young  man,  whose 
duties  included  the  daily  cleaning  of  cages  in  the  animal  room  and  whose 
hands  were  not  the  subject  of  much  thought  or  care,  soaked  his  hand 
(after  ordinary  washing)  on  ten  different  occasions  for  from  two  to  five 
minutes ;  and  each  time  each  nail  and  finger  was  tested,  i.  c,  ten  cultures 
were  made  In  seven  of  the  experiments  there  was  entire  absence  of 
growths ;  in  one,  a  growth  was  obtained  from  one  forefinger ;  in  one,  from 
one  middle  finger ;  and  in  one,  from  one  thum.b.  That  is  to  say,  of  100 
plantings  only  three  showed  growths. 

"At  the  Boston  City  Hospital,  Dr.  Monks  immersed  his  hands  for  two 
minutes  without  previous  scrubbing ;  the  skin  of  both  hands  gave  negative 
results,  but  growths  were  obtained  from  the  nails  of  the  right  hand ;  the 
nails  of  the  left  hand  were  sterile.  Three  of  the  assistants  did  the  same 
thing,  but  after  scrubbing.  The  hands  of  all  three  were  sterile ;  the  nails 
of  the  left  hand  of  one  assistant  gave  a  growth. 

"For  my  combination,  I  make  no  claims  whatever,  and  no  assertions 
that  later  might  have  to  be  recalled.  To  my  hands  and  to  those  of  my 
assistants,  the  mixture  has  caused  no  irritation  beyond  the  same  'Jegree 
of  biting  that  one  notices  when  in  contact  with  peroxide  of  hydrogen. 
Two  of  the  surgical  assistants  reported  slight  exfoliation  two  days  after 
trying  it,  but  nothing  more.  I  recognize  that  some  skins  may  be  more 
markedly  irritated,  and  that  not  sufiiciently  numerous  experiments  have 
been  made  to  warrant  unqualified  recommendation. 

"The  composition  of  the  mixture  is  as  follows : 

Commercial  alcohol   (94  per  cent.) • 640  cubic  centimetres 

Hydrochloric  acid   60  cubic  centimetres 

Water    , 300  cubic  centimetres 

Corrosive  sublimate   0.8  gramme 


I08  STERILIZATION    AND  DISINFECTION 

"This  mixture,  then,  contains  60  per  cent,  absohite  alcohol,  6  per  cent, 
commercial  (strong)  hydrochloric  acid,  and  1-1250  corrosive  sublimate. 
Now,  60  per  cent,  alcohol  will  destroy  Straphylococcus  aureus  in  four  min- 
utes;  10  per  cent,  hydrochloric  acid  is  equally  effective;  and  i-iooo  cor- 
rosive sublimate  will  kill  it  in  three  minutes.  Why  a  combination  con- 
taining all  three  substances,  but  Avith  lesser  proportions  of  the  acid  and  the 
salt,  is  so  much  quicker  in  its  action  than  any  one  of  them  alone,  is  an 
interesting  question  of  physical  chemistry." 


CHAPTER  XI. 

ANTISEPTICS  AND  DISINFECTANTS. 

It  is  impossible  in  the  limited  space  at  my  disposal  to  enter  into  a  de- 
tailed discussion  of  the  antiseptic  value  of  all  the  known  antiseptics.  I 
will,  however,  consider  the  most  important  and  those  commonly  used. 

Carbolic  Acid. — On  account  of  the  great  prominence  that  Lister  gave 
to  this  antiseptic,  it  should  be  considered  first. 

Pure  carbolic  acid  (phenol)  is  obtained  from,  coal-tar  oil  by  fractional 
distillation,  and  occurs  in  colorless  crystals  which  have  a  melting  point  of 
38.8''  C.  (104°  F.).  Carbolic  acid  crystals  are  soluble  in  water,  i  in  13; 
in  glycerine,  35^  in  i  ;  in  olive  oil,  i  in  2 ;  in  chloroform,  3  in  i ;  in  ether, 
4  in  I ;    in  alcohol,  6  in  1. 

Carbolic  acid  is  usually  used  in  a  20  per  cent,  solution.  This  is  too 
strong  for  the  hands  of  many  operators  without  the  immediate  use  of 
alcohol.  It  forms  insoluble  albumen  compounds  which  interfere  Avith  its 
germicidal  power.  If,  however,  carbolic  acid  is  combined  with  an  equal 
amount  of  hydrochloric  acid,  its  germicidal  action  is  greatly  increased.  A 
95  per  cent,  solution  of  carbolic  acid  applied  to  the  skin  acts  as  an  anesthetic, 
giving  a  sensation  of  numbness  and  coldness  wdth  a  loss  of  tactile  sensi- 
bility. Moist  dressings  of  5  per  cent,  strength  have  been  known  to 
cause  gangrene,  due  to  the  formation  of  thrombi  in  the  arterioles.  The 
absorption  of  carbolic  acid  into  the  system  is  first  made  manifest  by  the 
smoky  appearance  of  the  urine.  If  an  overdose  enters  the  circulation  it  is 
shown  by  pallor,  cyanosis  of  the  mucous  surfaces,  shallow  breathing,  dilated 
pupils,  feeble  pulse,  sub-normal  temperature  and  not  infrequently  delirium. 
If  the  dose  is  fatal,  convulsions  and  coma  usually  follow.  N.  Senn  has 
pointed  out  the  danger  of  using  strong  solutions  of  carbolic  acid,  and  men- 
tioned a  death  following  the  injection  of  a  few  drops  of  pure  carbolic 
acid  into  the  sac  of  a  hydrocele.  It  is  remarkable  that  when  95  per  cent, 
carbolic  acid  is  swallowed  in  sufficient  quantities  to  cause  death  coma  is 
one  of  the  first  manifestations.  I  have  made  it  a  practice  for  years  to  use 
95  per  cent,  carbolic  acid  on  account  of  its  excellent  anesthetic,  antiseptic, 
deodorizing  and  cauterizing  effects  without  any  deleterious  results.  If  alco- 
hol is  used  on  the  carbolized  surface  to  neutralize  the  continued  local  action 
of  the  acid,  there  is  practically  no  danger  of  carbolic  mtoxication.  The 
objection  to  using  carbolic  acid  on  the  hands  in  sufficient  strength  to  insure 
complete  germicidal  action  is  that  it  corrugates  and  anesthetizes  the  skin. 

The  experiments  made  to  determine  the  germicidal  powers  of  car- 
bolic acid  are  more  or  less  contradictory.  Sufficient  evidence  has  been 
adduced  to  show  that  carbolic  acid  requires  too  long  a  time  to   sterilize 


no  ANTISEPTICS   AND   DISINFECTANTS 

the  skin  of  the  patient  or  the  hands  of  the  surgeon.  Solutions  of  carboHc 
acid  and  oil  are  inert,  so  far  as  being  bactericidal  is  concerned,  and  solu- 
tions in  alcohol  and  glycerine  are  less  powerful  than  watery  solutions. 
Carbolic  acid  is  now  chiefly  used  in  antiseptic  surgery  for  the  preserva- 
tion of  materials  previously  sterilized,  such  as  gauze-sponges,  sutures,  liga- 
tures, etc.,  etc.  It  is  no  longer  employed  for  irrigathig  purposes  while 
operating,  for  it  only  irritates  the  parts,  induces  a  copious  flow  of  serum, 
and  not  infrequently  causes  superficial  tissue  necrosis.  Ninety-five  per 
cent,  carbolic  acid  disinfects  instruments  that  have  been  rendered  free  from 
fat  almost  instantaneously,  and  does  not  injure  them. 

Geppert  demonstrated  that  anthrax  spores  lived  in  a  7  per  cent,  solution 
for  38  days;  then  they  grew  in  agar-agar  and  finally  killed  guinea  pigs. 
Christmas  kept  anthrax  spores  in  a  20  per  cent,  solution  of  carbolic  acid 
for  a  month  without  lessening  their  vitality.  It  was  shown  by  Klein  that 
anthrax  bacilli  are  killed  in  five  minutes  by  a  5  per  cent,  carbolic  solution. 
Pyogenic  cocci  are  more  easily  destroyed  by  carbolic  acid  than  are  the  an- 
thi-ax  germs.  The  staphylococcus  aureus,  on  the  other  hand,  is  destroyed 
in  from  two  seconds  to  fifteen  minutes  by  a  5  per  cent,  solution. 

Other  Coal-Tar  Products. — Many  coal-tar  derivatives  besides  carbolic 
are  used  as  antiseptics  in  the  operating  room.  Lysol  is  a  brown  liquid,  alka- 
line in  reaction,  made  from  tar-oils.  It  is  used  in  solutions  of  one  to  two 
per  cent,  strength  for  cleansing  the  hands  or  skin.  It  has  a  soapy  feel. 
I  use  it  to  aid  in  pulHng  on  rubber  gloves.  When  the  gloves  are  filled 
with  the  lysol  solution,  the  hands  slip  into  them  with  comparative  ease.  It 
is  a  feeble  germicide  and  not  so  irritating  to  the  skin  as  carbolic  acid. 
What  remains  of  it  in  the  gloves  only  renders  the  hands  the  more  aseptic. 
Lysol  is  incompatable  with  acids.     It  is  highly  toxic. 

Creolin,  cyllin,  izol  and  other  coal-tar  products  are  more  useful  as 
deodorizers  than  as  disinfectants. 

Alcohol. — Alcohol  is  used  more  freely  than  any  other  antiseptic.  It 
is  a  powerful  germicide  in  the  strength  of  70  per  cent.,  but  is  of  no  value 
when  pure  (95  per  cent.).  In  disinfecting  the  hands  and  the  field  of  oper- 
ation it  removes  epidermal  scales  and  fat  from  the  skin,  abstracts  water, 
acts  germicidally  and  prepares  the  field  for  some  other  and  more  pene- 
trating agent.  In  conjunction  with  corrosive  sublimate  or  biniodide  of 
mercury  it  is  a  most  practical  and  efficient  antiseptic. 

Alcohol  kills  the  tubercle  bacillus  after  five  minutes'  exposure,  and  a 
40  per  cent,  solution  kills  pus  cocci  in  two  hours.  Sixty  to  seventy  per  cent, 
is  the  most  efficient  strength.  It  is  useful  for  disinfecting  instruments, 
basins,  sutures  and  ligatures,  and  for  preserving  materials  used  in  the 
operating  room. 

Corrosive  Sublimate  (Hg  CU). — Corrosive  sublimate,  also  known  as 
bichloride  of  mercury,  mercuric  chloride,  and  sublimate,  is  an  excellent  an- 
tiseptic and  disinfectant.  It  is  soluble  in  water,  alcohol,  ether  and  gl}'cer- 
ine.  It  is  soluble  in  water,  i  in  19 ;  in  absolute  alcohol,  i  in  3  ;  in  ether, 
I  in  6 ;  in  glycerine,  less  than  i  in  2.  It  is  a  powerful  poison  and  inay  kill 
by   absorption   from   the  skin   or  mucous  cavity.      It   formr,   an   albuminate 


m^m^^ 


PLATE  XVII. 
Inflamed  Hernia. 


ANTISEPTICS   AND    DISINFECTANTS  IIJ 

when  applied  to  the  tissues,  rendering  it  inert.  Even  in  aqneous  solutions- 
of  I  to  looo,  it  acts  as  a  great  irritant  to  the  hands  of  some  operators.  It 
restrains  the  development  of  anthrax  spores  in  as  weak  a  solution  as  i  in 
30,000,  and  it  kills  them  in  from  5  to  10  minutes  in  the  strength  of  ]-iooo. 
A  i-iooo  solution  kills  the  tubercle  bacillus  in  one  minute.  Growth  of  the 
pus  cocci  is  restrained  by  a  1-30,000  solution;  i-iooo  kills  them  in  from 
five  to  ten  minutes.  Sternberg  advocates  its  use  as  a  general  disinfectant 
in  i-iooo  or  1-500  solution  for  spore-containing  material,  and  in  1-5000 
or  1-2000  for  non-sporulating  pathogenic  bacteria.  Its  action  is  increased 
by  the  addition  of  hydrochloric,  picric  or  tartaric  acid. 

Harrington,  of  Boston  (as  before  stated),  has  demonstrated  that  in 
combination  with  hydrochloric  acid  and  alcohol  the  germicidal  action  is 
greater  than  that  of  either  one  alone.  The  chief  uses  to  which  corrosive 
sublimate  is  put  to-day  are:  (a)  To  disinfect  the  hands  of  the  operator; 
(b)  the  skin  of  the  patient;  (c)  to  sterilize  catgut,  as  well  as  in  the 
preservation  and  preparation  of  other  ligature  and  suture  materials. 

Solutions  of  corrosive  sublimate  are  poisonous,  sometimes  cause  der- 
matitis, lessen  the  resisting  power  of  the  tissues,  destroy  metallic  instru- 
ments, are  easily  decomposed  by  serum  and  purulent  discharges,  and  are 
incompatible  with  an  alkali.  Solutions  of  corrosive  sublimate  in  distilled 
water  become  reduced  in  strength  from  the  formation  of  an  oxide. 

Geppert  found  by  precipitating  the  mercury  with  amnionir.m  sulphide, 
thus  getting  the  inert  and  insoluble  sulphide,  that  pus  organisms  were  not 
killed  by  the  bichloride  solutions  as  was  formerly  supposed,  but  that  thev 
frequently  retained  their  vital  powers  of  infecting"  animals.  This  was  a 
revelation  to  those  operators  who  so  thoroughly  relied  on  sublimate  sciu- 
tions  as  a  disinfectani  in  conformity  with  the  bacteiToIogic  findings  of 
former  experimenters  wiio  asserted  that  staphylococci  (yellow)  were  killed' 
by  i-iooo  corrosive  sublimate  solution  in  a  few  seconds.  Since  Geppert's 
experimental  findings  have  been  verified  by  Abbott  m  Welch's  laboratory,, 
and  also  by  others,  corrosive  sublimate  as  a  disinfectant  is  not  considered 
as  being  infallible.  Sublimate  solutions  are  very  toxic,  and  it  is  icnown 
that  deaths  have  been  caused  by  prolonged  irrigation  of  wounds  with  these 
solutions.  I  recall  seeing  a  case 'of  sublimate  poisoning  in  consultation 
where  death  followed  the  use  of  an  intra-uterine  douche  (i-iooo)  for  sepsis 
after  a  miscarriage  in  the  third  month.  It  is  very  dangerous  to  irrigate 
raw  surfaces  with  this  poison.  Even  if  constitutional  symptoms  do  not 
arise,  local  necrosis  is  sure  to  occur.  In  pus  cases  irrigation  with  bichloride 
solutions  is  often  indicated.  One  may  begin  with  a  solution  of  the  strength 
of  1-5000  and  irrigate  till  one-third  is  used,  and  after  that  the  solution 
is  diluted  rapidly  to  i  in  20,000,  and  then  the  wound  is  irrigated  with  nor- 
mal salt  solution. 

■  Corrosive  sublimate  as  a  disinfectant  has  stood  a  long  practical  test, 
and  while  we  no  longer  wash  fresh  wounds  with  it,  still,  in  combination 
with  other  agents,  as  Harrington's  solution,  it  is  the  best  practical  germi- 
cide at  our  command  for  disinfecting  the  skin  of  the  patient  and  the  hands 
of  the  operator. 


114  ANTISEPTICS   AND   DISINFECTANTS 

Sal-aleinhroth  is  an  ammonic-merciiric-chloride.  It  is  soluble  in  water 
to  the  extent  of  less  than  its  own  weight.  "While  it  combines  with  albumen, 
it  does  not  do  so  as  readily  as  does  corrosive  sublimate.  It  is  used  in  the 
preparation  of  alembroth  gauze,  wools,  antiseptic  dressings,  etc.,  but  is 
very  objectionable. 

Biniodide  of  Mercury  (Potassio-Mercuric-Iodide). — This  substance 
is  spoken  of  very  highly  as  a  disinfectant.  Pearson  {Modern  Surgical  Tec- 
7iique  ill  Operations,  page  76)  says,  "Biniodide  possesses  the  following  ad- 
vantages as  compared  with  sublimate :  ( i )  It  is  a  more  powerful  germi- 
cide;  (2)  it  does  not  coagulate  albumen;  (3)  it  does  not  cause  precipita- 
tion with  blood,  except  when  the  latter  is  in  excess;  (4)  it  is  less  irritat- 
ing to  wounds ;  (5)  it  is  much  less  irritating  to  the  skin,  save  in  exceptional 
cases;  (6)  it  is  more  penetrating;  (7)  it  is  safer  for  washing  out  septic 
wounds  and  cavities,  being  less  toxic;  (8)  it  does  not  cause  any  immediate 
corrosion  of  metallic  instruments". 

Kanthack  and  other  bacteriologists  have  pointed  out  that  biniodide  of 
mercury  possesses  superior  germicidal  powers  than  bichloride.  It  has 
one  practical  disadvantage,  however,  as  compared  with  bichloride,  and  that 
is  its  much  greater  cost. 

Biniodide  Soliiiions. — Stock  solution   i  in   1000. 

Biniodide,  100  grams ;  potassium  or  sodium  iodide,  1000  grams ;  dis- 
tilled water,  icxdo  c.  c. 

By  dissolving  the  potassium  or  sodium  iodide  in  the  water  before  add- 
ing the  mercury  salt  a  clear  solution  is  obtained.  If  a  precipitate  is  thrown 
down,  the  solution  is  not  strong  enough ;  then  add  a  little  more  biniodide. 
The  strength  of  the  stock  solution  is  about  i  in  600.  If  colored  with  eosin 
it  will  not  be  mistaken  for  other  clear  fluids.  The  agent  can  be  obtained  in 
tablet  form.     One  tablet  to  a  gallon  of  water  makes  a  i  in  1000  solution. 

Alcoholic  solution  of  biniodide,  i  in  500,  is  the  one  recommended 
(Pearson)  for  disinfecting  the  hands.  It  is  made  by  adding  one  tablet  to 
5  ounces  of  water  (distilled),  and  15  ounces  of  90  per  cent  alcohol,  or 
methylated  spirits. 

A  70  per  cent,  alcoholic  solution  is  obtained  with  the  one,  and  67.5 
per  cent,  alcoholic  solution  with  the  other.  A  preserving  solution,  i  in 
1000,  for  the  preservation  of  Hgatures  and  suture  materials,  is  made  by 
adding  5  to  10  per  cent,  of  sterile  glycerine  to  the  alcoholic  solution. 

Iodine. — Iodine  is  a  very  useful  and  efficient  non-metallic  element.  It 
is  a  solid  at  the  ordinary  temperature.  It  is  slightly  soluble  in  water,  but 
by  adding  a  little  potassium^  or  sodium  iodide  it  dissolves  freely.  It  dis- 
solves in  alcohol,  i  in  10.  When  applied  to  the  skin  it  produces  a  stain 
and  acts  as  an  irritant,  rubefacient,  disinfectant  or  vesicant  according  to 
the  strength  of  solution  used  and  the  frequency  with  which  it  is  applied. 
For  complete  information  regardhig  iodine  as  a  germicide  I  refer  the 
reader  to  Senn's  article  on  'Todine  in  Surgery,  etc.''  {Journ.  of  Snrgery, 
Gynecology  and  Obstetrics,  July,  1905).  Senn  maintains  that  aqueous 
solutions  of  iodine  dest'-oy:  (i)  Actinomyces  (bovis)  (a)  i  in  500,  in  fif- 
teen minutes;    (b)   i  in  200,  in  one  minute.     (2)   Staphylococcus  pyogenes 


ANTISEPTICS   AND   DISINFECTANTS  II 5 

aureus,  i  in  200,  in  five  minutes.  (3)  Streptococcus  pyogenes,  i  in  500, 
in  two  minutes.  (4)  Anthrax  bacillus  and  its  spores,  i  in  100,  in  ten 
minutes.  (5)  Tubercle  bacillus:  (a)  i  in  200,  in  sixty  minutes;  (b)  i  in 
100,  in  seven  minutes. 

Senn  considers  iodine  the  safest  and  most  powerful  of  all  antiseptics. 
He  uses  it  to  disinfect  the  nails  as  the  last  step  (tincture).  It  is  used  in 
the  preparation  of  catgut. 

Iodoform. — In  hernia  operations  iodoform  has  a  place  as  a  dusting 
powder,  although  not  used  nearly  as  much  as  formerly.  It  is  soluble  in 
ether,  i  in  7 ;  chloroform,  i  in  14;  alcohol,  i  in  120;  olive  oil,  i  in  30; 
glycerine,  i  in  100.  When  absorbed  through  wounds  it  produces  poison- 
ing. Locally  iodoform  occasionally  causes  a  dermatitis,  vesicles  or  acute 
eczema.  It  has  many  objections.  It  has  a  disagreeable  odor,  and  it  is  a 
poor  antiseptic  and  does  not  kill  germs,  except  under  special  circumstances. 
In  the  tissues  of  the  hand,  in  granulation  tissue,  especially  in  tuberculous 
tissue,  iodoform  decomposes  in  from  3  to  5  da}s  in  the  absence  of  oxvgen, 
and  is  then  germicidal  in  its  action,  destroying  staphylococci  and  streptococ- 
ci. Heile  (An.  of  Surgery,  Dec,  1905)  thinks  the  decomposition  of  iodo- 
form in  the  presence  of  oxygen  sets  free  di-iodo-acetvlene — and  that  this  is 
the  germicidal  agent. 

Potassium  pcrmanganale,  in  5  per  cent,  solution,  kills  anthrax  spores 
in  twenty-four  hours.  The  dilute  solutions  used  for  irrigating  septic 
wounds  are  absolutely  worthless  so  far  as  their  antiseptic  action  is  con- 
cerned. They  are  usually  employed  hot,  and  to  the  heat  must  be  ascribed 
their  m»uch  vaunted  value  as  germicides.  Potassium  permanganate  is  de- 
composed easily  by  wound  secretions,  and  it  is  too  slow  in  action  for  the 
operating  room. 

Silver  nitrate  destroys  anthrax  spores  in  twenty-four  hours  in  a  i-io,- 
000  solution.  Behring  says  it  is  superior  to  mercuric  chloride.  It  is  very 
irritating,  and  combines  with  chlorides  and  albumins  to  form  insoluble 
silver  salts,  which  have  no  germicidal  value.  The  various  other  silver  salts 
(organic)  now  on  the  market  do  not  com.bine  with  the  albumins,  and 
are  less  irritating  than  the  nitrate,  but  the  clinical  reports  are  so  contra- 
dictory that  it  is  impossible  to  determine  their  antiseptic  value  with  any 
degree  of  positiveness.     Hardly  any  two  men  favor  the  same  compound. 

Boric  acid  is  practically  worthless  as  a  disinfectant.  A  saturated  solu- 
tion fails  to  kill  pus  cocci  in  two  hours.  It  is  a  very  weak  antiseptic.  A 
5  per  cent,  solution  failed  to  destroy  anthrax  spores  in  five  days  (Koch). 
It  is  used  very  widely  as  a  dusting  powder  on  w^ounds,  but  is  sometimes 
injurious.  It  is  a  good  solution  in  which  to  keep  soft  rubber  sterile  cathe- 
ters, etc. 

Pyoktannin. — Many  of  the  anilin  dves  are  germicides,  especiallv  blue 
pyoktannin  or  methyl  violet.  The  pus  cocci  and  anthrax  bacilli  are  killed 
in  thirty  seconds  by  a  i-iooo  solution  ;  the  typhoid  bacillus  in  thirty  min- 
utes. Malachite  green  possesses  even  greater  germicidal  value  than  >  pyok- 
tannin. The  objection  to  these  dyes  is  that  they  stain  and  discolor  the  tis- 
sues.    The  author  employs  them  to  stain  fistul?e  and  sinuses. 


Il6  ANTISEPTICS   AND   DISINFECTANTS 

Chlorine. — All  the  haloid  elements  are  active  germicidal  agents. 
Chlorine  combines  readily  with  hydrogen  and  hberates  nascent  oxygen.  It 
is  most  active  in  the  presence  of  moisture.  A  moist  atmosphere,  containing 
the  gas  in  the  proportion  of  1-2500,  kills  the  anthrax  bacillus  in  twenty- 
four  hours.  In  the  proportion  of  1-200  it  kills  the  tubercle  bacillus  in  an 
hour.     It  is  very  irritating  to  the  tissues. 

Hydrogen  Peroxide. — The  solutions  on  the  market  are  extremely  varia- 
ble i:i  strength  and  the  results  of  their  use  uncertain.  They  deteriorate  very 
rapidly.  Peroxide  is  used  principally  for  cleansing  suppurating  wounds,  as 
it  possesse^^-  the  power  of  liberating  nascent  oxygen,  which  oxidizes  the 
purulent  secretions. 

In  order  to  carry  out  the  principles  presented  in  this  chapter,  special 
requirements  must  be  met  before  aseptic  surgical  technic  can  claiip  superior 
results  quite  apart  from  the  operator's  skill  in  surgical  procedures  and  his 
knowledge  of  hernias.  These  requirements  are  the  sterilization  and  disin- 
fection of  everything  that  may  come  in  contact  with  the  wound.  The  first, 
if  not  the  most  important,  is  to  render  the  hands  and  forearms  of  the 
operator  and  his  assistants  surgically  clean.  The  hands  are  always  covered 
with  bacteria  while  performing  their  everyday  functions.  It  is  true  that  a 
surgeon  who  knows  the  dangers  of  infection  can  and  does  keep  his  hancis 
out  of  abscesses,  and  does  not  handle  septic  cases  without  rubber  gloves, 
or  examine  the  mouth,  vagina  or  .rectum  with  bare  hands ,  but  in  spite  of 
all  ordinary  precautions  that  he  can  possibly  observe  against  coming  in 
contact  with  virulent  pyogenic  organisms  his  hands  v/ill  get  dirty  and  in 
that  dirt  lurk  the  sources  of  inflammation  and  all  that  inflammation  im- 
plies. 

It  is  a  very  difficult  task  to  destroy  all  the  germs  and  their  spores  on 
the  hands,  under  the  nails,  and  in  the  follicles  of  the  skin  without  destroy- 
ing the  skin  at  the  same  time.  Indeed,  so  discouraging  has  this  task  been 
that  many  authorities  consider  it  hopeless  to  try  to  render  the  hands  com- 
pletely aseptic  (Needham-Green  "On  the  Sterilization  of  the  Hands," 
1904),  realizing  that  a  person  can  go  so  far  and  no  farther.  Year  by 
year  a  little  more  information  has  been  gained  until  now  we  can  say  that 
the  hands  of  some  persons  at  least  may  be  disinfected  so  thoroughly  in  a 
few  minutes  as  to  fail  the  detection  of  germs.  A  man  who  operates  almost 
every  day  and  uses  antiseptic  reagents,  such  as  mercuric  chloride,  has  his 
skin  impregnated  thoroughly  with  the  drug.  It  is  easy  to  see  that  his  hands 
are  less  liable  to  implant  pus  germs  into  the  wound  than  are  the  hands  of 
one  vv'ho  operates  only  occasionally.  In  evidence  of  this  sublimated  con- 
dition of  the  deep  skin  let  me  say  that  if  such  an  operator  will  rub  lanolin 
into  the  skin  of  his  hands  and  forearms  for  fifteen  minutes,  he  will  suffer 
the  symptoms  of  salivation.     This  observation  I  verified  on  myself. 

THE  TOILET  OF  THE  HANDS  AND  FOREAEMS. 

Keep  them  clean.  Avoid  scratches  or  abrasions  by  wearing  gloves  when 
driving,  fishing  or  hunting.  If  you  receive  scratches,  disinfect  them  and 
apply  collodion  for  protection.     Ungual  tags  should  be  removed  and  pro- 


PLATE   XVIII. 
Ulcerated  Hernia. 


ANTISEPTICS   AND   DISINFECTANTS  II9 

tected  in  the  same  manner.  Any  one  who  has  a  pustule  or  suppvirating 
wound,  be  it  ever  so  small,  should  consider  himself  incapacitated  from 
operating  or  assisting  at  an  operation.  The  wearing  of  rubber  gloves  does 
not  excuse  him  for  operating.  The  nails  should  be  kept  short  to  pre- 
vent the  accumulation  of  extraneous  matter  and  to  enable  one  to  have 
free  access  to  the  subungual  spaces  for  their  disinfection. 

The  forearms  should  be  kept  free  from  hair  by  shaving  them  every  few 
weeks.  It  always  gives  me  a  shudder  to  see  a  hairy  arm  enter  the  ab- 
dominal cavity.  There  is  no  reason  why  this  precaution  should  not  be 
practised.  Rough  and  horny  hands  require  more  time  for  their  disinfection 
than  those  with  smooth  and  flexible  skin.  A  good  plan  to  train  assistants, 
internes  and  nurses  to  take  the  time  required  to  scrub  the  hands  in  soap 
and  water  in  order  to  remove  gross  dirt,  is  to  ask  each  of  them  before 
scrubbing  first  to  anoint  the  hands  and  forearms  with  an  ointment  cf 
powdered  charcoal.  It  will  teach  them  that  it  requires  much  more  time, 
patience  and  perseverance  to  rid  the  skin  of  black  dirt  than  they  anticipat- 
ed. If  germs  were  visible  to  the  naked  eye,  what  an  interminable  job  it 
would  be  to  scrub  them  off ! 

One  secret  of  preventing  the  hands  from  cracking  is  to  scrub  them 
carefully  after  each  operation  in  order  to  remove  all  traces  of  blood,  and 
then  rub  any  ointment  that  is  sterile  and  feebly  antiseptic  into  the  crevices 
and  follicles  of  the  skin,  and  with  sterile  towel  rub  off  the  redundant  oint- 
ment. I  find  this  to  be  an  excellent  aid  in  keeping  the  hands  in  a  cosmetic 
state.  If  called  in  consultation,  and  it  is  deemed  best  to  examine  septic 
places  on  or  in  the  body,  which  would  undoubtedly  befoul  my  hands  if  not 
protected,  and  if  rubber  gloves  are  not  available,  I  feel  that  some  security  is 
obtained  by  smearing  the  hands  with  sterile  vaseline,  or  some  cerate,  before 
making  the  examination. 

While  scrubbing  the  hands  with  soap  and  water  preparatory  to  per- 
forming an  operation,  care  must  be  exercised  not  to  reinfect  the  hands  by 
touching  septic  brushes,  towels,  water  taps,  etc.  In  every  well-furnished 
operating  room  an  automiatic  arrangement  is  provided  to  turn  the  water 
on  and  off  without  the  use  of  the  hands. 

The  simple  technic  of  scrubbing  the  hands  is  so  frequently  faulty  in 
aseptic  precaution  that  I  am  constrained  to  dwell  on  it.  In  training  ama- 
teurs in  surgical  technic  I  have  frequently  given  no  instructions  whatever, 
but  simply  ask  them  to  scrub  up.  Each  in  turn  picks  up  a  sterile  nail 
brush  in  one  hand  and  a  chunk  of  soap  in  the  other  and  at  once  begms  a 
vigorous  scrubbing  of  the  one  and  then  of  the  other  hand.  Is  not  this  the 
usual  way  to  begin  the  scrubbing  process?  Yes,  but  it  is  wrong,  and  there 
is  danger  of  autoinfection  from  the  germs  beneath  the  nails  and  on  the 
skin  being  forcibly  rubbed  into  an  abrasion  created  by  the  brush  or  into  a 
raw  surface  previously  present.  It  is  only  recently  that  an  able  surgeon 
lost  his  life  from  auto-streptococcic  infection  received  in  this  way. 

The  skin  of  the  hands  should  be  softened  by  washing  them  in  soap 
and  water  in  the  old-fashioned  way  before  applying  the  brush.  This  process 
not  only  renders  the  skin  less  liable  to  injury  from  a  stiff  bristle  in  the 


120  ANTISEPTICS   AND   DISINFECTANTS 

brush,  but  it  also  removes  the  gross  source  of  iufectioii.  This  1  call  a  pri- 
mary scrub,  and  it  should  be  done  with  warm  sterile  running  water  in  a 
room  used  for  this  purpose.  One  may  at  once  poke  his  fingers  deeply  into 
the  soapdish ;  another  sticks  to  the  same  brush  throughotit 
the  entire  process,  or  reinfects  his  nails  with  his  penknife  taken  from  his 
pocket,  or  touches  spectacles,  or  even  wipes  them  with  a  clean  (  ?)  pocket 
handkerchief,  after  finishing  his  scrubbing.  A  sterile  nail  file  should  be  used 
not  after  the  cleansing  process  with  brush,  soap  and  water,  but  somewhere 
in  the  middle  of  the  process.  The  nail  file  removes  softened  masses  not  as 
yet  reached  by  the  brush  and  thus  its  use  should  not  be  left  to  the  last. 

In  order  to  receive  the  greatest  benefit  from  soap  and  water  cleansing 
with  brush,  about  fifteen  minutes  should  be  consumed  in  the  operation. 

1.  Five  minutes  with  soap  and  warm  water. 

2.  Five  minutes  with  fresh  sterile  soft  soap,  sterile  brush  and  flowing 
water. 

3.  Use  nail  file  or  scalpel. 

4.  Five  minutes  with  fresh  sterile  soap ;  fresh  sterile  brush  and 
water  flowing  freely  on  the  forearms  and  hands. 

It  must  be  remembered  that  one  man  is  capable  of  doing  more  cleans- 
ing in  five  minutes  than  another  does  in  double  that  time.  It  has  been 
proven  bacteriologically  that  the  hands  are  not  freed  from  dangerous  bac- 
teria by  scrubbing  with  soap  and  water,  and  in  respect  to  this  fact  some 
chemical  germicidal  reagent  must  be  used  to  destroy  the  remaining  bacteria 
on  the  skin.  The  nails  should  be  manicured  once  a  week.  Any  abrasioi. 
caused  is  at  once  protected  with  a  drop  or  two  of  equal  parts  of  iodine  and 
collodion. 

Methods  of  Hand  Disinfection  : — 
Pearson's  Method. 

1.  Scrubbing  with  soap  and  water  and  changing  brushes  for  five 
minutes. 

2.  Methylated  spirits  rubbed  on  hands,  nails  and  forearms  for  three 
minutes. 

3.  Spirituous  solution  of  biniodide  (i  in  500)   for  two  minutes. 

4.  Biniodide  wiped  ofif  with  meth3dated  spirits. 

In  the  case  of  one  whose  hands  are  well  cared  for  the  process  may 
be  accomplished  in  seven  minutes,  viz :     "Washing  stage  three   minutes ; 
alcohol  stage,  two  minutes;  biniodide  stage,  two  minutes." 
Kocher's  Method. 

1.  Wash  the  hands  thoroughly  with  soap  and  brush  under  steaming 
hot  water. 

2.  Wash  ofif  the  soap  with  flowing  warm  water. 

3.  Scrub  with  alcohol   (85  per  cent.)   inch  by  inch. 

4.  Wash  ofif  alcohol  with  stream  of  warm  sterile  water. 

This  process  is   for  hands  cared  for  surgically.      For  hig-hly   infected 
hands  he  recommends  an  additional  scrubbing  and  bathing  with  sublimate 
solutions  of  I  in  500,  or  i  in  loco,  in  strength. 
Furhrino-ers  Method. 


ANTISEPTICS   AND   DISINFECTANTS  121 

1.  Scrub  with  soap  and  water  for  three  minutes. 

2.  Immerse  hands  and  forearms  in  95  per  cent,  alcohol  for  one  min- 
ute, using  the  scrubbing  brush  to  remove  fats,  etc. 

3.  Wash  hands  and  forearms  in  sublimate  solution  i  in  1000. 

In  regard  to  the  use  of  alcohol  as  a  disinfectant,  it  has  been  shown  that 
70  per  cent,  alcohol  is  more  germicidal  than  95  per  cent.  Harrington  has 
proven  that  a  sublimate  solution,  i  in  1000,  is  not  as  potent  a  germicide 
alone  as  when  it  is  combined  with  70  per  cent  alcohol  and  6  per  cent,  hydro- 
chloric acid. 
Permanganate  of  Potash  and  Oxalic  Acid  Method. 

This  method  does  not  stand  the  bacteriologic  test,  and  is  only  men- 
tioned to  be  condemned.      (See  experiments  of  Leedham-Green  and  Har- 
rington.)     It  has  been  used  extensively  in  Johns   Hopkins'   Hospital  and 
for  a  time  most  American  surgeons  employed  it. 
Chlorinated  Lime  Method. 

This  process  is  cumbersome,  but  is  practised  more  or  less.  It  con- 
sists of  the  following  steps : 

1.  Scrub  as   usual. 

2.  Take  a  handful  of  chlorinated  lime  and  make  a  paste  of  it  with 
warm  water. 

3.  Take  another  handful  of  crushed,  crystalline  washing  soda  and 
mix  it  with  the  lime  paste  between  the  hands,  and  then  thoroughly  rub  it 
into  the  skin  until  the  roughness  of  the  soda  is  no  longer  felt  but  a 
sensation  of  heat  is  felt,  due  to  the  liberation  of  chlorine  gas. 

4.  Rinse  the  hands  in  a  two  per  cent,  solution  of  ammonia  to  remove 
the  odor. 

Rubber  Gloves.  After  the  hands  are  sterilized  the  operator  may  use 
rubber  gloves  for  two  purposes,  (a)  to  keep  the  hands  aseptic,  and  (b)  to 
guard  against  infection  of  the  wound  from  the  hands.  In  hernia  opera- 
tions and  in  all  aseptic  surgical  procedures  the  latter  is  the  prime  con- 
sideration. That  they  obtund  the  sensibility  of  the  fingers  there  is  no  rea- 
son to  doubt  and  the  thicker  the  glove  the  greater  the  loss  of  normal  tactile 
sense. 

In  consideration  of  the  uncertain  asepticity  of  the  hands  obtained  by 
scrubbing  and  by  disinfectants,  especially  in  the  case  of  surgeons,  assist- 
ants and  nurses  who  have  not  studied  bacteriology  to  any  great  extent  (and 
these  include  the  vast  majority  of  persons  who  operate  or  who  assist  at 
operations),  and  also  in  view  of  the  rapidity  wath  which  gloves  on  the 
hands  may  be  rendered  aseptic  with  95  per  cent,  carbolic  acid,  i  in  200 
bichloride;  pure  lysol,  etc.,  it  is  reasonable  to  conclude  that  less  infection 
of  wounds  occurs  during  operations  when  rubber  gloves  are  worn.  When 
the  hands  are  not  aseptic,  the  gloves  are  reinforced  in  pulling  them  on. 

In  cases  demanding  surgical  interference  so  emergently  that  there  is 
no  time  to  scrub  up,  an  assistant  may  put  the  gloves  on  the  septic  hands 
of  the  operator.  If  the  gloves  are  not  sterile  and  speedy  action  is  a  life- 
saving  element,  then  it  is  admissible  to  put  the  gloves  on  dirty  hands  and 
sterilize  them  immediately  as  already  mentioned.     On  more  than  one  occa- 


122  ANTISEPTICS   AND   DISINFECTANTS 

sion  I  have  thus  performed  what  might  be  called  a  cyclone  operation 
aseptically,  saved  my  patient's  life  and  secured  primary  healing-  of  the 
wound.  It  is  the  man  who  knows  most  about  the  science  of  surgery  who 
generally  carries  out  the  best  operative  technic. 

Rubber  gloves  were  first  used  in  America  by  Halsted.  They  are  now 
used  by  surgeons  in  almost  every  clinic  room  in  this  country.  There  is 
no  doubt  in  my  mind  but  that  the  most  recent  data  regarding  hand  disin- 
fection will  materially  limit  their  employment. 

Gloves  should  be  worn  when  operating  on  septic  cases  and  also  when 
dressing  so-called  pus  cases.  The  assistants  should  wear  gloves  for  the 
same  reasons.  When  the  operator  or  his  assistants  have  any  abrasions  on 
the  hands,  it  is  to  their  own  interest  to  wear  rubber  gloves  while  handling 
or  operating  on  an  infected  case.  The  gloves  must  be  thin,  as  thin  as 
is  consistent  with  durability,  and  they  must  fit.  They  should  be  boiled 
in  a  I  or  2  per  cent,  solution  of  soda,  and  before  being  put  on  the  hands 
they  are  filled  with  an  aqueous  solution  of  lysol  in  order  to  continue  the 
disinfection  and  to  prevent  their  being  torn.  The  objection  to  a  dusting 
powder  within  the  gloves  and  on  the  hands  is  that  it  is  an  additional  ob- 
struction to  the  sense  of  touch.  Most  operators  strip  the  gloves  over  the 
fingers  as  they  would  a  leather  glove,  but  it  is  much  better  to  use  a  soft  hand 
brush  for  this  purpose. 

The  gloves  when  torn  may  be  repaired  very  readily  either  by  means 
of  a  rubber  cement  or  by  applying  a  small  patch.  The  cement  is  used 
for  very  small  tears  and  for  punctures,  while  the  patch  is  used  for  the  re- 
pair of  larger  tears  and  welded  with  the  Paquelin  cautery. 

Although  it  is  not  quite  as  satisfactory  to  operate  with  the  hands  cov- 
ered by  rubber  gloves  as  it  is  to  operate  without  gloves,  yet  the  interests 
of  both  patient  and  operator  outweigh  the  inconvenience  that  is  caused  by 
the  wearing  of  the  gloves.  Their  use  insures  greater  cleanliness,  thus  min- 
imizing the  danger  of  infection.  The  operator  protects  himself  from  in- 
fections of  all  kinds,  particularly  from  syphilitic  infection,  a  matter  of  con- 
siderable importance. 


CHAPTER  XII. 

STERILIZATION  OF  CATGUT. 

Raw  catgut  is  always  infected.  It  has  been  demonstrated  by  Lock- 
wood  and  others  that  when  catgut  is  prepared  for  surgical  ligatures  and 
sutures  only  with  carbolic  acid,  juniper  oil  or  chromic  acid,  ^growths  of 
bacteria  from  many  specimens  occurred  in  gelatine  and  agar-agar.  Car- 
bolic acid  in  oil  loses  much  of  its  germicidal  power  and  therefore  carbolic 
oil  is  no  longer  relied  upon  to  sterilize  catgut.  The  idea  of  employing 
antiseptic  suture  and  ligature  material  that  is  absorbable  is  indisputably 
the  correct  one,  but  care  must  be  taken  to  render  the  material  sterile  at  the 
same  time.  While  raw  catgut  cannot  stand  steam  sterilization  or  boiling  in 
water  with  impunity,  it  may  be  made  sterile  by  boiling  it  in  oil,  such  as 
cumol,  and  after  being  prepared  in  formalin  or  chromic  acid  it  will  even 
stand  fractional  sterilization  in  boiling  water. 

The  catgut  employed  for  ligating  vessels  and  suturing  in  the  per- 
formance of  operations  for  the  cure  of  hernias  must,  first,  not  be  a  source 
of  infection;  second,  it  must  not  be  absorbed  before  nature's  healing  tissue 
(fibrous  tissue)  is  developed  and  is  sufficiently  strong  to  prevent  an  inter- 
mediate breaking  open  of  the  wound  by  yielding  to  intra-abdominal  pres- 
sure. To  forestall  these  two  calamities  the  raw  catgut  must  be  sterilized 
so  that  it  will  not  infect  the  wound,  and  so  that  it  will  not  be  hardened  or 
its  condition  changed  to  withstand  the  action  of  the  tissues  for  the  required 
time  to  prevent  relapses  of  the  hernia. 

It  is  not  my  intention  to  present  all  or  nearly  all  that  has  been  developed 
in  the  line  of  catgut  sterilization,  but  I  wish  to  describe  the  best  and  most 
practical  methods  in  vogue.     We  have  the  following  at  our  command : 

I.  Aseptic  catgut  produced  by 

1.  Dry  heat  sterilization. 

2.  Cumol    (Kronig)   method. 

3.  Alcohol. 

II.  Antiseptic  catgut  prepared  by 

1.  Carbolic  acid    (now  discarded). 

2.  Bichloride  of  merciu'v  (Esmarch). 

3.  Biniodide   (Lockwood). 

4.  Bergman  method. 

5.  Iodine    (Claudius). 

6.  Chromic  acid. 

7.  Ochsner's   method. 

8.  Heat  and  iodine  (Bartlett). 

9.  Formalin   (Hofmeister). 

10.     Formalin  and  chromic  acid  (Ferguson). 


124  STERILIZATION    OF    CATGUT 

Dry  Heat  Sterilisation. — Benekiser  and  Boeckmann  have  siiccessfiiily 
sterilized  catgut  by  dry  heat.  I  consider  Boeckmann's  method  the  better 
of  the  two.  The  catgut,  cut  in  suitable  lengths,  is  wrapped  in  paraffin 
paper  and  is  then  tightly  sealed  in  small  envelopes.  A  special  box  is  filled 
with  these  little  envelopes  placed  on  edge  and  is  then  packed  in  the  steril- 
izer. The  temperature  of  the  sterilizr  is  gradually  raised  until  it  reaches 
284''  F.  to  300'^  F.,  and  it  is  maintained  there  for  at  least 
three  hours,  which  renders  the  catgut  entirely  free  from  germs  and  spores. 
For  very  thick  catgut,  such  as  No.  5,  the  process  is  repeated.  Plain  dry 
sterile  Boeckmann  catgut  has  been  used  for  over  a  dozen  years  by  many 
of  the  most  prominent  surgeons  in  the  United  States  and  Canada. 

Pyoktanin  dry  catgut  (Boeckmann)  is  a  later  production.  Small  sizes 
of  Boeckmann's  dry  catgut  are  absorbed  easily  and  for  ligation  of  deep- 
seated  vessels  in  sterile  localities  this  catgut  is  ideal.  The  smaller  the 
strand  the  shorter  the  time  for  its  absorption.  I  have  used  it  for  several 
years  and  have  learned  to  respect  the  small  sizes  and  to  fear  the  larger 
ones,  either  for  ligatures  or  sutures.  In  my  clinic  at  the  College  of  Medi- 
cine of  the  University  of  Illinois  pyoktanin  catgut  has  been  used  in  all 
kinds  of  hernial  operations  for  several  years  with  universal  satisfaction. 

Tlie  Alcohol  Method. — A  strong  metal  cylinder  with  a  closely  fitting 
screw  cap  is  half  filled  with  absolute  alcohol.  The  catgut  is  cut  in  suitable 
lengths,  rolled  and  put  into  the  cylinder  with  the  alcohol.  The  cap  is 
screwed  on  very  tightly  and  then  the  cylinder  thus  prepared  is  placed  in 
boiling  water  (100*'  C),  wdiere  it  is  kept  for  half  an  hour.  Inas- 
much as  the  boiling  point  of  alcohol  is  78.3"  C,  and  the  heat  ap- 
plied is  100'^  C,  the  alcohol  in  the  vessel  is  heated  under  pressure, 
which  is  said  (Jellett)  to  kill  anthrax  spores.  When  catgut  prepared  by 
alcohol  is  left  in  the  tissues  of  the  body,  the  alcohol  soon  leaves  the  catgut 
and  then  it  is  practically  an  aseptic  catgut.  The  same  objections  that  hold 
good  for  the  one  pertain  to  the  other. 

Esmarch's  Method. — Raw  catgut  is  freed  from  fat  by  (a)  brush,  .soap 
and  water,  and  then  water  to  remove  the  soap,  or  (b)  by  ether.  When 
wound  on  glass  spools  it  is  sublimated  (1:1000)  for  12  hours;  it  is  then 
transferred  to  sublimated  alcohol,  i  to  200,  for  12  hours,  and  finally  is 
preserved  dry  in  closely  fitting  glass  vessels  Just  before  use  it  is  placed 
in  sublimated  alcohol,  i  to  2000. 

Lockivood  Method. — Catgut  wound  on  a  board  is  treated  as  follows : 

I.  Scrub  with  soap  and  water  and  remove  the  soap.  2.  Submerge 
in  ether  to  insure  removal  of  fat.  3.  Keep  in  an  aqueous  solution  of 
biniodide  of  mercur}^  i  to  250.  This  catgut  is  not  to  be  used  until  it  has 
been  soaked  in  water  for  "2  hours. 

Von  Bergiiiann's  MetJwd. — This  is  described  in  detail  by  Schimmel- 
busch.     The  essential  features  of  it  are  the  following : 

Raw  catgut  is  wound  on  glass  and  is  placed  in  ether  for  24  hours. 
It  is  then  allowed  to  lie  in  the  following  solution  for  48  hours,  the  solution 
being  changed  at  the  end  of  the  first  24  hours : 


PLATE   XIX. 


Gans:renous   Hernia. 


STERILIZATION    OF    CATGUT  I27 

Bichloride  of  mercury   ■ lo 

Absolute  alcohol   800 

Distilled    water    200 

The  gut  is  kept  in  absolute  alcohol  if  a  hard  product  is  desired,  or  in 
alcohol  (80  per  cent.)  and  glycerin  (20  per  cent.)  if  a  soft  gut  is  wanted. 
This  preparation  of  catgut  has  stood  both  the  experimental  and  clinical  test 
in  Von  Bergmann's  clinic. 

Cumol  Method. — Kronig's  method  is  the  boiling  of  catgut  in  cumol 
to  effect  its  sterilization.  Clark  and  Miller  modified  the  process.  The  cat- 
gut is  cut,  wound  in  loops  and  slipped  into  test  tubes.  The  gut  is  gradually 
heated  up  to  80'^  C,  maintained  for  one  hour;  is  then  placed  in 
cumol  and  the  temperature  raised  to  165'^  C,  and  there  main- 
tained for  an  hour,  when  the  oil  is  poured  off  and  the  gut  dried,  either  by 
the  heat  of  the  sand-bath,  or  in  a  hot  air  oven  for  two  hours.  It  has  not 
found  general  favor,  especially  in  operations  for  hernia,  and  it  is  only 
mentioned  to  be  condemned.  The  same  objections  hold  true  to  it  as  to 
other  forms  of  aseptic  catgut. 

Iodized  catgut  is  prepared  after  the  method  of  Claudius.  The  "raw" 
catgut,  rolled  on  a  glass  tube,  is  immersed  in  the  following  solution  for 
eight  days : 

Iodine,  i  part;   potassium  iodide,  i  part;   water,  100  parts. 

First  make  a  solution  of  K  I,  gr.  i  to  m.  j.,  to  which  finely  powdered 
iodine  and  then  the  100  parts  of  water  are  added.  Commercial  catgut  kept 
in  this  solution  for  a  week  will  be  antiseptic  and  ready  for  use.  It  is  pre- 
served in  this  solution  or  in  an  alcoholic  solution  of  the  same  strength. 

Abbott's  chromic-iodised  catgut  is  very  simply  prepared.  The  raw 
gut  is  immersed  in  1-2000  aqueous  solution  of  chromic  acid  for  24  hours, 
and  is  then  iodized  for  eight  days  after  the  method  of  Claudius.  It  is  then 
transferred  to  95  per  cent,  alcohol,  in  which  it  remains  ready  for  use. 

Aloschcovitz,  of  New  York,  transfers  the  iodized  (Claudius) gut  at  the 
end  of  eight  days  to  a  dry  sterile  jar,  which  prevents  it  from  becoming 
brittle.  It  is  used  dry  from  the  jar.  The  advantages  claimed  for  the 
iodized  catgut  are : 

(i)  Absolutely  sterile  (dry)  ;  (2)  not  infectable;  (3)  not  deleteriously 
irritating;  (4)  not  impaired  in  tensile  strength;  (5)  prepared  easily  and 
cheaply;    (6)  absorbable  after  serving  its  purpose. 

Abbott's  Iodized  Catgut. — Abbott,  of  Minneapolis,  has  pointed  out 
that  half  the  quantity  of  iodine  used  by  Claudius  will  readily  sterilize  the 
raw  catgut,  and  that  it  is  less  brittle  and  irritating.  He  uses  only  two 
sizes,  fine  and  medium,  and  these  may  be  used  for  sewing  the  skin,  the  fine 
thread  lasting  for  a  week.  An  excellent  test  of  the  antiseptic  properties  of 
catgut  prepared  with  chemicals  is  that  it  may  be  used  in  sewing  skin  with- 
out the  formation  of  stitch  abscesses. 

Abbott's  Chromic  Catgut. — Raw  catgut  is  immersed  for  24  hours  in  a 
1-2000  aqueous  solution  of  chromic  acid,  after  which  it  is  sterilized  in  the 
iodide  solution  (Claudius).  After  eight  days  transfer  to  95  per  cent,  alco- 
hol and  use  from  that  medium.     Brittleness  is  avoided  by  preparing  smaller 


128  STERILIZATION    OF    CATGUT 

batches  which  will  last  a  short  time.  After  two  years'  experience  Abbott 
is  perfectly  satisfied  with  it. 

Ochsner's  Method. — After  inmiersion  in  sulphuric  ether  for  one  month, 
the  catgut  is  placed  in  strong  commercial  alcohol  in  which  gr.  i  to  ^i  ^f 
corrosive  sublimate  has  been  dissolved.  The  solution  is  renewed  once  dur- 
ing the  month.  It  is  then- preserved  indefinitely  in  the  following  solution: 
Iodoform,  i  part ;   ether,  5  parts ;   commercial  alcohol,  14  parts. 

This  catgut  remains  intact  in  the  tissues  for  from  seven  to  ten  days, 
according  to  the  size  used.  The  above  is  used  as  a  ligature  and  suture 
everywhere,  except  in  bone  and  hernia  operations,  for  which  ptu-poses 
Ochsner  employs  chromicized  catgut,  which  lasts  from  15  to  30  days,  ac- 
cording to  the  size  used.     It  is  prepared  as  follows : 

Ochsner's  Chromicised  Catgut. — The  catgut  is  immersed  in  ether  for 
one  month,  then  in  a  solution  prepared  in  the  following  manner:  (A) 
Chromic  acid,  i  part;  water,  5  parts;  dissolve  carefully.  (B)  Take  of 
solution  A  I  part ;    glycerine,  i  part. 

Soak  the  catgut  in  solution  B  for  forty-eight  hours  or  more,  according 
to  the  resistance  wanted.  Catgut  soaked  for  forty-eight  hoars  will  resist 
absorption  by  the  tissues  for  fifteen  days,  whereas  catgut  soaked  for  nine- 
ty-six hours  will  resist  absorption  for  thirty  days. 

(C)  Take  catgut  out  of  B  solution,  rinse  quickly  but  thoroughly  in 
sterilized  water;  wind  on  rods  or  slidei^  at  least  three  inches  in  length, 
and  preserve  indefinitely  in  the  following  solution : 

(D)  Carbolic  acid,  95  per  cent,  i  part;  glycerine,  5  parts. 

The  catgut  may  remain  in  this  solution  for  many  months  without  de- 
preciating in  quality,  or  it  may  be  kept  for  an  indefinite  period  of  time  in 
the  same  solution  as  the  ordinary  catgut: 

Iodoform,  i  part;   ether,  5  parts;    strong  alcohol,  14  parts. 

The  ''ar  containing  the  ether  in  which  the  catgut  is  kept  for  one  month 
should  be  filled  only  about  one-half  with  the  loose  coils  of  ligature,  and 
then  it  is  filled  with  ether.  The  jar  should  be  shaken  in  an  inverted  posi- 
tion every  day  or  two  in  order  to  wash  ofif  any  substance  which  may  accu- 
mulate on  the  surface  of  the  coils.  At  the  end  of  two  weeks  the  ether 
should  be  replaced  by  fresh  ether.  The  same  precaution  should 
be  taken  with  the  solution  of  corrosive  sublimate  in  alcohol.  It 
is  especially  important  not  to  wind  the  catgut  tightly  before  it  is  placed 
in  these  solutions,  because  this  may  prevent  the  solutions  from  penetrating 
all  parts  of  the  material.  One  precaution  is  necessary  in  the  use  of  catgut 
prepared  in  this  manner — it  must  be  placed  in  _water  before  it  is  used  at 
the  time  of  the  operation. 

The  Bartlett,  or  Heat  and  Iodine  Method. — i.  The  raw  catgut,  thirty 
inches,  is  coiled  on  itself ;  several  coils  are  strung  together  and  hung  in  a 
beaker  glass,  not  touching  sides  or  bottom.  A  thermometer  enters  the 
beaker  through  a  hole  in  the  pasteboard  covering  it;  Htjuid  petrolatum  is 
now  poured  into  the  beaker  sufficient  to  immerse  the  catgut  and  bulb  of  the 
thermometer  and  the  preparation  for  sterilization  is  complete. 

2.    The  prepared  beaker  is  now  "set  upon  a  pan  of  sand  under  which  is 


STERILIZATION    OF    CATGUT  I29 

placed  a  tiny  gas  flame  of  merely  sufficient  intensit}^  to  raise  the  tempera- 
ture of  the  oil  to  212'^'  F.  within  one  to  two  hours".  This  tempera- 
ture is  maintained  over  night  (a  variation  of  a  few  degrees  does  not  mat- 
ter). '"The  heat  is  then  increased  to  the  extent  that  the  temperature  will 
run  up  to  300''  F.  in  the  course  of  an  hour ;  then  the  gas  is  turned 
off  and  the  temperature  of  the  oil  allowed  to  return  to  about  212'^". 
The  sterilization  by  heat  is  thus  completed. 

3.  The  catgut  coils  are  lifted  out  of  the  beaker,  the  oil  is  allowed 
to  drop  off,  and  then  for  chemical  sterilization  and  preservation  the  coils 
are  dropped  into  the  following  mixture : 

Columbian  spirits,  too  parts ;    iodine  flakes,  i  part. 

It  is  ready  for  use  and  will  not  deteriorate.  When  it  is  desirable  to 
make  catgut  last  longer  than  usual,  Bartlett  recommends  hardening  the 
catgut  as  above  prepared  in  formalin  vapor.  He  suspends  the  coils  a  few 
inches  above  a  10  per  cent,  formalin  solution  in  an  air-tight  vessel  for 
twenty-four  hours.  This  process  is  simple  and  the  catgtit  requires  no 
washing.  It  is  stated  that  No.  2  catgut  so  treated  will  last  in  muscle  for 
from  two  to  three  weeks.     (American  Practice  of  Surgery ^  Vol.  I,  p.  733.) 

Formalin  Catgut  (Hofmeister). — It  appears  that  formaldehyde  effects  a 
change  in  raw  catgut  which  enables  it  to  withstand  boiling  in  water,  with- 
out lessening  its  tensile  strength.  It  also  endows  it  with  a  property  of 
resisting  phagocytosis.  Formalin  catgut  may  be  sterilized  fractionally  by 
boiling.     This  renders  it  absolutely  sterile. 

According  to  Pearson,  whose  method  is  a  modification  of  Hofmeister's, 
the  formalin  catgut  may  be  prepared  somewhat  as  follows :  Raw  catgut  is 
wound  in  single  layers  on  large  frames  so  that  the  formaldehyde  may 
have  free  access  to  it  from  all  sides.  It  is  then  immersed  for  from  12  to 
48  hours,  according  to  the  size  of  the  catgut,  in  formalin  solution,  vary- 
ing in  strength  from  2  to  4  per  cent.  In  order  to  rid  it  of  the  formalin,  v/hicu 
is  too  irritating  for  the  tissues,  a  stream  of  cold  water  is  allowed  to  pass 
through  it  for  24  hours.  The  gut  is  then  wound  on  glass  reels  or  slides,  and 
is  boiled  in  water  for  from  10  to  25  minutes,  according  to  the  thickness  of 
the  gut.  It  is  then  preserved  indefinitely  in  alcohol.  If  an  aseptic  catgut 
is  desired,  instead  of  preserving  it  in  alcohol,  it  is  preserved  in  sterile  glass 
vessels. 

Formalin  Chromic  Catgut  (Ferguson). — For  the  last  seven  or  eight 
years  I  have  used  a  catgut  known  by  the  name  of  "Chromoform"  catgut, 
or  Hollister's  catgut,  for  which  Air.  Hollister  received  testimonials  from 
many  of  the  best  surgeons  and  gynecologists  in  Chicago  and  the  West. 
It  was  prepared  after  my  direction  and  gave  great  satisfaction.  It  was 
first  put  through  the  formaldehyde  process  and  was  then  subjected  to 
chromic  acid  solution,  ^  of  i  per  cent.,  for  24  hours,  then  transferred  to 
alcohol  in  glass  tubes,  which  were  permanently  sealed.  This  was  rendered 
both  aseptic  and  antiseptic  catgut  in  its  preparation. 

When  a  tube  of  this  catgut  v/as  broken  and  only  one  or  two  ligatures 
or  sutures  were  used,  the  remainder  could  withstand  boiling  two  or  three 
times  with  but  slight  diminution  of  its  tensile  strength. 


CHAPTER  XIll. 

THE  WOUND. 

In  operations  for  the  relief  of  hernia  the  wound  is  ahvays  an  incised 
one,  and  is  made  deliberately  by  the  operator.  It  may  be  defined  as  a 
solution  of  continuity  of  the  several  structures  necessarily  encountered  and 
severed  in  hernia  operations.  When  a  wound  is  made  under  proper  aseptic 
and  antiseptic  precautions,  it  is  called  an  aseptic  wound,  and  it  heals  by 
primary  union.  All  wounds  that  are  made  with  instruments  not  sterile,  or 
in  skin  not  disinfected  may  be  considered  infected  wounds. 

If  the  surgeon  implants  living  organisms  into  the  wound  by  acci- 
dental contact,  and  suppuration  ensues,  the  wound  is  said  to  be  primarily 
infected,  and  this  may  be  either  superficial  or  deep.  When  an  aseptic 
wound  is  undergoing  primary  repair,  and  becomes  infected  accidentally 
through  a  shifting  of  the  dressings,  or  because  of  the  patient  passing  his 
hands  over  the  wound  surface  in  order  to  feel  of  the  cut,  infection  is  said 
to  be  secondary. 

As  already  pointed  out  in  a  previous  chapter,  wound  infection  may 
be  autogenetic  or  heterogenetic.  A  diseased  wound  is  one  in  which  some 
pathogenic  bacteria  find  a  suitable  pabulum  for  their  multiplication,  as,  for 
instance,  in  tuberculosis.  The  bacillus  of  tuberculosis  must  be  lodged  in 
the  wound  before  the  disease  manifests  itself.  A  closed  wound  is  one  in 
which  the  coaptation  of  the  severed  structures  has  been  accomplished  by 
sutures.  An  open  wound  is  one  in  which  the  edges  have  not  been  approx- 
imated. It  is  usually  packed  with  gauze.  Many  other  appellations  are 
given  to  wounds  according  to  their  appearance  and  condition,  such  as  a 
healing,  granulating  and  suppurating  wound. 

The  terms  femoral,  inguinal,  and  umbilical  are  applied  to  a  wound 
because  of  its  location. 

The  Incision. — It  requires  considerable  art  to  make  a  correct  incision 
in  the  various  hernial  regions.  Any  one  can  slash,  but  it  takes  an  artist 
to  cut.  No  matter  what  variety  of  hernia  is  being  operated  on,  the  primary 
incision  should  be  ample  enough  so  that  the  operation  can  be  completed 
without  tearing  or  bruising  the  edges  of  the  wound.  The  skill  of  the 
operator  always  is  made  manifest  by  the  manner  in  which  he  handles  the 
knife,  and  the  judgment  he  displays  in  deciding  on  the  length  and'  depth 
of  the  primary  incision. 

The  first  stroke  of  the  scalpel  should  carry  it  through  the  skin  only, 
and  for  the  full  length  of  the  wound  (Figs.  23  and  24).  Until  the  opera- 
tor has  gained  sufficient  knowledge  of  the  requirements  of  the  various 
incisions,    and    until    he    gains    by    experience    the    force    required    to    cut 


PLATE  XX. 
Gangrenous  (Littre's)  Hernia. 


THE    WOUND 


133 


A  wi 


through  the  skin  that  is  loose  or  taut,  thick  or  thin,  it  is  a  good  plan  first 
to  outline  the  skin  incision  with  the  sharp  point  of  the  scalpel.  Then  an 
assistant  puts  the  skin  on  the  stretch,  while  the  operator  makes  his  incision 
in  the  line  of  the  scratch  previously  made. 

After  performing  this  act  two  or  three  hundred  times,  the  operator 
may  venture  to  cut  loose  skin  and  make  a  proper  incision  with  one  sweep 
of  the  knife.  It  is,  however,  difficult  to  accomplish  this.  To  cut  more  than 
the  skin  with  the  first  stroke  of  the  knife  shows  a  lack  of  surgical  knowl- 
edge and  skill.  It  is  not  brilliant  to  sever  all  the  structures  down  to  the 
hernial  sac  with  one  stroke.  I  have  seen  men  of  limited  experience  so 
foolhardy  as  to  attempt  this,  the  result  being  that  they  cut  through  the 
bowel. 

An  ordinary  scalpel  has  performed  its  function  during  the  operation 
when  it  has  incised  the  skin.  Of  course,  this  depends  to  some  extent  on 
the  quality  of  the  blade,  but  usually  making  the  incision  dulls  the  knife 
so  that  it  is  not  fit  for  further  use  until  sharpened.  Another  reason  for  not 
using  this  scalpel  again  during  the  operation  is  that  in  passing  through  the 
appendages  of  the  skin  it  may  become  septic. 

In  operations  for  the  cure  of  hernia,  great  care  should  be  exercised 
not  to  do  anything  that  will  tend  to  lower  the  vitality  of  the  structures 
that  have  been  cut.  Powerful  retraction  and  forcible  tearing  of  the  tissues 
with  the  fingers,  with  gauze  or  with  the  tissue  comb  must  be  avoided.  Fre- 
quent mopping  of  the  wound  with  gauze  also  injures  the  tissues,  and  it  is 
quite  unnecessary,  provided  the  surgeon  is  careful  in  his  hemostasis.  Clean 
cutting  and  clean  dissection  traumatize  the  tissues  but  little,  thus  favor- 
ing primary  union. 

Exposing  the  Deep  Structures. — The  deep  structures  that  must  be 
considered  in  these  operations  are  situated  immediately  around  and  within 
the  sac.  In  oblique  inguinal  hernia  care  should  be  taken  not  to  injure  the 
spermatic  cord,  the  deep  epigastric  vessels,  the  internal  iliac  vessels,  or  the 
deep  abdominal  muscles.  Having  split  the  aponeurosis  of  the  external 
oblique,  the  deep  abdominal  muscles  can  be  exposed  easily  by  locating  the 
conjoined  tendon,  and  then  the  cremaster  fibers  may  be  dissected  away 
from  the  lower  border  of  the  internal  oblique  muscle. 

The  sac  is  best  exposed  at  the  internal  ring  by  picking  up  its  neck 
with  tissue  forceps.  It  is  then  severed.  It  is  not  often  that  the  cord  is 
front  of  the  sac.  It  is  usually  situated  behind  or  to  the  side  of  it.  Be- 
fore opening  the  neck  of  the  sac  the  vas  deferens  should  be  located  and 
injury  to  it  avoided.  In  stripping  the  sac  from  its  surrounding  structures 
gauze  must  be  used  if  the  tissues  have  become  blood-stained.  If  the  sur- 
geon is  careful,  however,  this  tearing  with  gauze  is  avoided.  Once  a  clear 
line  of  cleavage  next  the  sac  is  obtained,  it  should  be  followed  to  the  limit. 

The  deep  epigastric  vessels  are  situated  immediately  behind  the  root 
of  the  cord.  When  exposing  these  vessels  the  cord  must  be  draw^n  to  one 
side  and  the  transversalis  fascia  severed.  This  will  at  once  uncover  these 
vessels,  whicn7  however,  fs" hot  usually  necessary.  The  point  to  remember 
in  exposing  the  deep  structures  outside  of  the  sac  is  to  do  the  work  in  such 


134 


THE    WOUND 


^vki 


J  t^ 


a  manner  as  to  differentiate  clearly  every  structure  that  is  encountered. 
The  deep  structures  inside  of  the  sac,  the  intra-abdominal  structures,  are 
cared  for  according  to  the  condition  of  the  sac  contents  and  the  relation- 
ship existing-  between  the  sac  and  these  structures. 

If  the  hernia  is  strangulated,  partially  strangulated,  or  incarcerated, 
the  grooved  director  should  never  be  passed  underneath  the  strangulating 
band,  because  it  may  penetrate  the  bowel  and  it  also  bruises  the  tissues 
because  of  its  being  forced  underneath  the  constricting  band.  This  band 
should  be  severed  carefully  by  cutting  from  without  inwards.  If  any  ad- 
hesions are  present  at  the  neck  of  the  sac,  the  sac  should  then  be  opened 
above  the  constricting  band  rather  than  below  it. 

Similar  precautions  should  be  taken  when  dissecting  out  the  deep 
structures  in  cases  of  femoral,  obturator,  umbilical  or  other  forms  of 
hernia. 

Hemorrhage. — The  control  of  hemorrhage  during  operations,  on  her- 
nia, no  matter  whether  the  hemorrhage  is  arterial,  venous  or  capillary,  is 
not  a  difficult  matter  in  normal  subjects.  The  hemorrhage  that  comes 
from  beneath  the  skin  should  not  be  allowed  to  stain  the  structures,  even 
at  the  expense  of  somewhat  lowering  the  vitality  of  these  tissues.  It  is 
good  surgery  to  clamp  the  bleeding  vessels  with  the  mosquito  forceps 
represented  in  Fig.  22.  Ligatures  should  be  tised  as  little  as  possible  in 
hernia  operations.  In  oblique  inguinal  hernia  it  is  permissible,  at  times, 
to  ligate  the  superficial  vessels.  I  have  frequently,  however,  operated  on 
an  oblique  inguinal  hernia  without  making  use  of  a  single  ligature,  ex- 
cept that  which  surrounds  the  neck  of  the  sac.  The  angiotrypsic  forceps 
shown  in  Fig.  kJ  is  sufficient  to  arrest  all  bleeding,  but  I  should  not  advise 
clamping  the  deep  epigastric  vessels  and  trust  to  the  crush  thus  made  for 
^permanent  hemostasis.  These  should  be  tied  with  catgut.  Hemorrhage 
from  the  omentum  must  also  be  checked  by  means  of  the  ligature,  or  the 
vessels  may  be  cooked  with  the  electro-thermic  hemostat  (Downes).  Ac- 
cidental injuries  to  the  larger  vessels  must  be  dealt  with  on  general  sur- 
gical principles. 

Before  attempting  to  close  the  wound,  the  operator  must  assure  him- 
self that  there  is  no  oozing  from  any  vessels.  The  arrest  of  primary  hem- 
orrhage must  be  complete  in  order  to  get  the  best  results.  The  applica- 
tion of  styptics  of  any  kind  is  to  be  deprecated.  I  have,  however,  used  an 
antiseptic  dusting  powder,  such  as  iodoform,  in  order  to  arrest  capillary 
hemorrhage  by  favoring  rapid  coagulation  of  the  blood  by  means  of  a 
substance  that  is  feebly  antiseptic.  Experience  has  taught  me  that  an 
antiseptic  powder  which  is  feebly  antiseptic,  applied  in  small  quantities, 
does  not  interfere  with  primary  union.  If  the  wound  is  not  carefully 
closed  and  dressed,  hemorrhage  may  take  place,  and  this  is  particularly 
liable  to  occur  when  the  scrotum  has  been  opened  during  the  operation. 

Closing  the  Wound. — The  first  structure  to  be  closed  is  the  perito- 
neum. The  sac  is  usually  ablated  below  the  ligature.  In  some  hernias  it 
is  preferable  to  suture  the  peritoneum  exactly  as  is  done  in  closing  an  or- 
dinary abdominal  section.     The  principal  point  to  be  remembered  in  clos- 


PLATE  XXI. 


I.  Ferguson's  angiotripsic  straight  forceps.  2.  Ferguson's  angiotripsic 
curved  forceps.  3.  Ferguson's  angiotripsic  straight  clamp.  4.  Ferguson's 
angiotripsic  curved  clamp.  5.  Halstead's  curved  forceps.  6.  Halstead's 
straight  forceps.     7.  Barrett's  bowel  holder. 


THE    WOUND 


137 


ing  the  peritoneal  wound  is  that  smooth  surfaces  must  be  brought  in  con- 
tact, so  that  the  raw  edges  are  turned  outward.  Inasmuch  as  union  of  the 
peritoneum  depends,  in  the  main,  on  the  amount  of  traumatism  inflicted, 
the  sutures  should  be  placed  closely  together.  It  is  preferable  to  use  a 
continuous  suture.  The  rest  of  the  wound  may  be  coaptated  in  one  of  two 
ways :  First,  by  means  of  through-and-through  sutures ;  and.  second,  by 
the  insertion  of  deep  and  superficial  sutures. 

Xo  matter  what  method  of  suturing  is  adopted,  care  should  be  ob- 
served that  no  dead  spaces  exist  after  the  wound  has  been  closed.  A 
through-and-through  suture  in  hernia  operations  v^as  long  ago  found 
wanting  and  it  has  been  practically  discarded,  with  the  exception  of  the 
through-and-through  retention  suture,  which  is  fastened  to  buttons  or 
rolls  of  gauze  placed  at  some  distance  from  the  incision. 

In  ventral  and  umbilical  hernias  occurring  in  very  stout  people,  these 
through-and-through  retention  sutures  lend  security  to  the  deep  and  super- 
ficial sutures. 

The  deep  structures  are  either  brought  together  edge-to-edge  or  they 
are  overlapped.  Often  in  bringing  them  together  edge-to-edge  there  is 
more  or  less  crowding  of  the  tissues  so  that  they  form  a  ridge.  When 
union  by  first  intention  takes  place  these  structures  practically  are  as 
strong  as  normally.  Overlapping  of  the  tissues  is  to  be  deprecated,  except 
when  they  can  be  imbricated  without  tension. 

All  the  structures  may  be  approximated  either  with  absorbable  or 
non-absorable  suture  material.  AA'hen  the  absorbable  material,  such  as 
catgut  or  kangaroo  tendon,  is  used,  it  is  safer  to  insert  an  interrupted 
suture  than  a  continuous  one.  If  a  continuous  suture  gives  way  under 
the  influence  of  overstraining  caused  by  vomiting,  or  if  it  becomes  absorbed 
too  rapidly,  the  breaking  at  one  point  will  loosen  the  entire  stitching.  The 
interrupted  sutures,  on  the  other  hand,  support  one  another,  which  is  a 
decided  advantage.  If  one  suture  gives  way,  the  adjoining  sutures  will 
still  keep  the  tissues  in  approximation. 

The  skin  may  be  closed  with  chromic  catgut,  pyoktannin  or  formalin 
catgut,  or  a  combination  of  these.  All  catgut  that  is  used  for  the  skin  must 
be  antiseptic  or  so  hardened  that  it  is  not  absorbed  too  rapidly.  For  clos- 
ing the  skin  wound  I  prefer  to  use  horsehair  in  the  form  of  a  continuous 
buttonhole  stitch.  In  fleshy  people  it  is  always  necessary  to  coaptate  the 
fat  by  means  of  retention  sutures  because  otherwise  there  will  be  a  large 
dead  space  between  the  sutured  skin  and  the  aponeurotic  structures  be- 
neath the  fat.  If  non-absorbable  suture  material  is  used  to  close  the 
wound  throughout,  the  sutures  must  be  applied  in  such  a  manner  that  they 
can  be  removed  easily  after  union  has  taken  place. 

The  subcuticular  wire  or  silkworm  gut  suture  I  do  not  favor  at  all 
for  the  reasons  already  mientioned. 

The  wound  should  be  closed  as  rapidly  as  possible,  because  the  longer 
it  is  exposed  fo  the  air,  the  greater  is  the  danger  of  infection,  and  a  pro- 
longed anesthesia  is  very  likely  to  cause  an  irritation  of  the  kidneys. 

Drainage. — It  is  not  very  often  that  drainage  is  necessar}'  after  hernia 


138  THE    WOUND 

Operations.  When  it  is,  tubes  of  any  kind  should  not  be  used. 
When  it  is  evident  that  the  tissue  wih  be  overtaxed  in  the 
absorption  of  primary  and  secondary  wound  secretions,  a  drain  should  be 
inserted.  A  capillary  drain  usually  is  all  that  is  required  to  meet  this  in- 
dication. In  very  large  scrotal  hernias,  when  a  large  sac  has  been  dis- 
sected out  of  the  scrotum,  and  large  raw  surfaces  are  left,  the  cavity 
readily  becomes  filled  with  blood  serum.  Here  we  have  an  indication  for 
capillary  drainage,  and  silkworm  gut,  chromic  catgut,  horsehair  or  wire 
may  be  used  for  this  purpose.  The  drain  is  inserted  in  the  lowest  part 
of  the  wound,  and  is  passed  down  and  out  through  the  most  dependent 
portion  of  the  scrotum,  thus  securing  perfect  drainage  without  interfer- 
ing with  the  dressings  in  any  way.  If  the  wound  becomes  septic,  drain- 
age may  have  to  be  resorted  to,  and  maintained  by  tubes  or  gauze. 

Dressings. — Experience  has  taught  us  that  after  having  completed 
an  operation  for  hernia,  it  is  necessar}-  to  place  a  dressing  on  the  wound, 
(a)  to  prevent  decomposition  and  infection,  and  (b)  to  support  the  parts 
and  keep  them  at  rest  while  repair  is  in  progress.  For  the  simple  protec- 
tion of  the  wound  a  collodion  dressing  usually  fulfills  all  the  indications. 
When  the  wound  is  not  being  drained  and  when  there  is  no  oozing  of 
blood  serum,  before  the  Collodion  dressing  is  applied  the  skin  must  be 
wiped  off  with  ether  or  alcohol,  so  as  to  obtain  an  absolutely  dry  sur- 
face to  which  the  collodion  can  adhere.  This  dressing  it  is  well  to  inter- 
mix with  thin  layers  of  cotton  or  gauze  or  both,  but  care  must  be  exercised 
that  the  dressing  is  not  too  thick,  for  otherwise  irritation  and  even  vesica- 
tion of  the  underlying  skin  may  take  place.  If  the  dressing  does  not  ex- 
tend some  distance,  at  least  a  couple  of  inches,  beyond  the  edge  of  the  in- 
cision, it  may  become  loosened  and  thus  furnish  an  avenue  through  which 
infection  may  enter  the  wound.  If  the  collodion  dressing  does  become 
loosened,  it  should  be  removed  at  once.  I  sometimes  use  a  sterile  antisep- 
tic powder  in  conjunction  with  the  collodion.  Equal  parts  of  collodion, 
and  iodine  may  be  applied  to  the  wound  and  the  surrounding  skin  as  a 
primary  application.  This  antiseptic  may  prevent  the  formation  of  stitch 
abscesses  and  suppuration  underneath  the  collodion  dressing. 

Even  in  all  those  cases  treated  primarily  with  the  collodion  dressings 
an  external  dressing  of  gauze  pads  should  be  employed  to  support  the 
abdomen  for  a  few  days  at  least  until  all  tendency  to  retching  and  vomit- 
ing has  subsided.  While  the  dressing  is  being  applied  it  is  important  that 
the  patient  should  be  kept  sufficiently  under  the  influence  of  the  anesthetic 
to  prevent  any  struggling  and  to  minimize  the  effect  of  intra-abdominal 
pressure.  The  supporting  dressings  of  gauze  pads  and  so  forth  should  be 
of  such  a  nature  as  to  also  protect  the  wound  from  infection.  I  use  either 
plain  sterile  gauze  or  gauze  that  is  impregnated  with  some  antiseptic 
agent.  It  is  then  known  as  an  antiseptic  dressing  gauze.  Dressings,  there- 
fore, are  either  aseptic  or  antiseptic. 

Nearly  all  antiseptic  dressings  have  a  tendency  to  irritate  the  skin. 
I  have  seen  an  extensive  dermatitis  follow  the  use  of  iodoform  gauze,  car- 
bolized  gauze,  and  even  bichloride  gauze,  but  I  have  never  seen  dermatitis 


PLATE  XXII. 


8.  Needle  holder  (Ferguson).  9.  Mayo's  dissecting  scissors.  10.  By- 
ford's  retractor.  11.  ^^layo's  retractor.  12.  Ferguson's  retractor.  13.  In- 
testinal needles  (Mayo).  14.  Ferguson's  round  needles.  15.  Ferguson's 
needles  with   cutting  edge.     16.   Tissue  forceps. 


THE    WOUND  141 

follow  the  use  of  gauze  prepared  according  to  Lister's  method,  the  so-called 
cyanide  of  mercury  gauze.  The  skin  is  never  irritated  if  only  plain  ster- 
ilized gauze  is  used. 

When  dressing  hernia  wounds  in  the  region  of  the  groin,  especially 
in  children,  I  invariably  place  several  layers  of  antiseptic  gauze,  prefer- 
ably iodoform  gauze,  over  the  sterile  gauze  that  is  placed  next  to  the  skin. 
The  manner  in  which  the  gauze  dressing  is  applied  has  both  a  practical  and 
a  scientific  bearing.  The  first  three  or  four  layers  of  gauze  should  cover 
the  wound  only.  The  next  few  layers  should  extend  slightly  beyond  the 
edges  of  the  wound,  and  so  on  with  each  succeeding  layer,  until  the  wound 
is  covered  by  a  pad  of  gauze  from  one-half  to  three-fourths  of  an  inch  in 
thickness,  and  extending  beyond  the  edges  of  the  wound  for  four  or  five 
inches.  The  reason  for  placing  the  gauze  in  this  manner  is  that  absorp- 
tion cannot  take  place  from  the  periphery  of  the  gauze  directly  into  the 
wound.  Secretions  of  any  kind  are  taken  up  by  the  upper  layers  which 
override  the  lower,  thus  protecting  the  wound  itself  for  a  considerable 
period  of  time  from  the  irritating  action  of  these  secretions. 

This  gauze  pad  is  then  covered  with  an  antiseptic  dressing  which 
most  effectually  prevents  infection  of  the  wound  even  though  the  dress- 
ings become  soiled  from  within  or  from  without. 

In  order  to  prevent  this  gauze  dressing  from  shifting,  a  combination 
dressing  must  be  applied  which  extends  completely  around  the  thigh  and 
two-thirds  around  the  body. 

To  prevent  the  wound  from  being  injured  by  strain  of  any  kind,  it 
is  advisable  to  protect  this  external  dressing  with  broad  adhesive  straps 
sc  arranged  as  to  receive  the  bulk  of  the  force  from  within,  just  as  a  truss 
gives  support  to  a  hernial  region.  Take,  for  instance,  a  case  of  oblique 
inguinal  hernia.  An  extra  pad  is  placed  over  the  inguinal  region  and  an 
adhesive  strap  is  applied,  passing  across  the  abdomen  below  the  anterior 
superior  spines  of  the  ilia,  exactly  in  the  truss  line.  This  strip  of  plaster 
v»'ill  receive  the  force  at  the  internal  ring.  Another  strip  of  plaster  should 
extend  from  the  ribs  down  over  the  line  of  incision,  fitting  closely  the  fold 
of  the  groin,  passing  backward  along  the  gluteal  fold,  and  then  forward 
again  across  the  upper  portion  of  the  leg,  and  over  the  inguinal  region 
immediately  in  front  of  the  internal  ring.  This  strap  should  extend  up- 
ward, crossing  the  umbilicus  and  ending  on  the  opposite  side  of  the  body, 
just  beneath  the  ribs.  Over  these  straps  I  wind  a  roll  of  broad  gauze  which 
completes  the  dressing. 

In  children  rubber  tissue  or  oiled  silk  is  placed  over  the  dressing  so 
as  to  keep  it  dry.  Some  operators  apply  a  plaster  cast  over  the  dressing, 
but  this  is  too  heavy,  and  it  may  cause  pain  by  pressing  on  bony  promi- 
nences, and  when  the  edges  of  the  cast  become  soiled  they  are  exceedingly 
irritating  to  the  skin  and  the  cast  must  be  removed. 

The  dressing  may  remain  in  place  for  two  or  three  weeks,  if  neces- 
sary, but  inasmuch  as  it  becomes  rather  uncomfortable,  and  as  the 
stitches  may  have  to  be  removed  before  that  time,  it  is  advisable  to  change 
the  primary  dressing  inside  of  a  Aveek.     If  drainage  has  been  established 


142  THE    WOUND 

the  dressing  should  be  removed  within  three  days.  Even  though  the 
dressings  may  be  saturated  with  blood  serum  within  twenty-four  hours  after 
operation,  it  is  not  necessary  to  remove  them  because  of  any  danger  of 
infection  occurring.  Of  course,  it  must  be  borne  in  mind  that  some  bac- 
teria travel  along  the  skin  more  rapidly  than  others,  and  I  have  in  mind 
now  particularly  the  streptococcus. 

After  the  primary  dressing  has  been  removed,  any  drain  that  may 
have  been  inserted  should  be  withdrawn  carefully.  Silkworm  gut  drains 
are  cut  off  at  the  lower  angle  of  the  wound  and  are  then  withdrawn  from 
the  opposite  angle,  so  that  contamination  of  the  wound  surfaces  cannot 
take  place. 

The  same  precautions  are  taken  in  the  application  of  the  primary  dress- 
ing in  the  femoral  region,  or  in  anv  other  hernial  region.  In  ventral  and 
umbilical  hernias,  before  the  adhesive  straps  are  applied,  I  place  two  rolls 
of  combination  dressing,  one  on  each  side  of  the  wound,  running  in  its 
long  axis,  so  that  the  pressrire  is  exerted  laterally  instead  of  centrally.  In 
very  large  ventral  and  um.bilical  hernias,  instead  of  passing  the  adhesive 
straps  two-thirds  around  the  body,  I  pass  them  completely  around,  over- 
lapping the  straps  in  the  center,  in  which  position  they  give  a  better  and 
a  more  rigid  support. 

The  technic  of  removing  the  primary  dressing  is  one  of  considerable 
importance.  The  dressing  should  be  removed  in  such  a  manner  as  not  to 
expose  the  wound  to  contamination  any  .more  than  is  necessary.  With  this 
end  in  view  all  the  dressings  are  removed,  except  the  primary  gauze,  which 
was  placed  immediately  over  the  wound.  The  skin  surrounding  this  dress- 
ing is  then  bathed  with  alcohol,  or  bichloride  solution,  or  Harrington's 
solution.  Then  sterile  towels  are  placed  around  this  area  and  not  until 
then  should  the  wound  be  exposed  by  the  removal  of  the  primary  dressing. 

The  wound  is  now  inspected  carefully ;  stitch-hole  infections  are  look- 
ed for.  If  the  wound  is  found  to  be  in  perfect  condition,  a  second  dress- 
ing is  applied  with  the  same  care  as  the  first.  It  is  left  in  place  four  or  five 
days,  after  which  a  pad  of  gauze  and  a  spica  bandage  is  all  that  is  nec- 
essary. 

Removal  of  Sutures. — Catgut  sutures  that  are  not  causing  any  irri- 
tation may  be  allowed  to  remain  in  place  until  they  are  absorbed.  Silk- 
^yorm  gut  sutures  should  be  removed  from  the  skin  inside  of  twelve  days. 
Half  of  the  number  of  stitches  may  be  removed  at  the  time  the  primary 
dressing  is  changed,  and  the  other  half  when  the  second  dressing  is  taken 
ofT.  If  these  sutures  are  allowed  to  remain  in  the  skin  a  longer  time  than 
this,  they  begin  to  cut  through,  cause  irritation,  and  favor  the  development 
of  stitch  abscesses. 

Subcuticular  stitches  of  wire  should  be  removed  at  the  end  of  a  week, 
unless  they  are  not  loosened  sufficiently  at  that  time,  when  they  are  left 
in  place  a  few  days  longer.  Deep  wire  and  silkworm  gut  stitches  that  are 
removable  should  be  left  in  place  for  about  three  weeks,  until  wound  heal- 
ing has  progressed  to  the  stage  of  fibrous  tissue  formation.  If  these 
stitches  are  removed  too  soon,  while  the  wound  is  still  granulating,  a  very 


THE    WOUND  ,^, 


Slight  degree  of  intra-abdominal  pressure  is  sufficient  to  cause  separation 
or  the  wound  edges. 

The  antiseptic  dusting  powder  may  be  used  freely  over  the  stitch- 
ho.es,  so  as  to  prevent  abscess  formation.  If  infection  has  occurred,  two 
thmgs  must  be  done,  (a)  irrigate  and  wash  the  stitch  holes  with  some  anti- 
septic solution  and  (b)  cut  the  stitch  at  a  point  where  it  has  been  buried 
and  then  withdraw  it  from  the  other  side. 

Horsehair  sutures  are  removed  at  the  end  of  a  week. 


CHAPTER  XIV. 

TREATMENT  OE  WOUNDS. 

^^'ol.mds  are  either  aseptic  or  septic,  and  the  treatment  required  for 
each  is  quite  different. 

Aseptic  Wounds.  A  wound  that  is  aseptic  will  heal  by  first  intention, 
if  the  treatment  employed  is  such  as  to  prevent  secondary  infection.  The 
sole  aim  of  the  treatment,  therefore,  is  to  prevent  secondary  infection. 
The  dressing  must  be  applied  properly  as  is  pointed  out  under  the  head- 
ing of  Dressings.  The  wound  and  surrounding  parts  must  be  maintained 
in  a  state  of  physiological  rest,  the  stitches  must  not  be  tied  too  tightly 
and  the  tissues  of  the  patient  must  be  in  a  healthy  condition,  and  he  must 
have  sufficient  natural  powers  to  carry  on  repair.  If  the  dressings  bear 
too  tightly  on  a  wound  immediate  repair  is  delayed.  If,  on  the  other  hand, 
the  dressings  are  too  loosely  applied  they  are  liable  to  shift  and  expose  the 
wound,  which  is  an  indication  to  renew  the  dressing. 

If  the  patient  has  passed  the  hand  underneath  the  dressings,  imme- 
diate disinfection  of  the  wound  should  be  carried  out,  and  new  dressings 
applied.  If  the  patient  complains  of  great  discomfort  and  tenderness  in 
the  region  of  the  wound  at  the  end  of  forty-eight  hours  the  wound  should 
be  inspected.  This  pain  is  not  infrequently  caused  by  an  accumulation  of 
blood  serum  beneath  the  skin  or  in  the  tissues.  If  such  is  found  to  be  the 
case  the  blood  serum  should  be  allowed  to  escape  and  the  wound  dressed 
aseptically  and  antiseptically,  and  a  new  dressing  applied.  If  the  dress- 
ings become  saturated  with  blood  and  blood  serum,  at  the  end  of  twenty- 
four  hours,  it  is  better  to  change  the  external  dressings.  But  a  wound  is 
not  in  danger  of  infection  from  this  source  for  about  three  days,  when 
all  the  dressings  should  be  renewed.  If  the  dressings  become  soiled  from 
without  bv  extraneous  matter,  urine,  etc.,  that  is  an  indication  for  their  re- 
moval. 

In  hernial  cases,  where  a  large  semilunar  flap  is  made  at  the  time  of 
the  operation,  an  accumulation  of  secondary  wound  secretion  is  liable 
to  take  place  beneath  it,  unless  the  dressings  are  properly  applied.  If 
such  a  secretion  is  present  at  about  the  end  of  a  week,  when  the  first  dress- 
ing is  changed,  it  should  be  allowed  tO'  escape  through  an  opening  made 
by  the  removal  of  a  stitch,  and  then  the  dressing  applied  so  as  to  exert  some 
pressure  on  the  flap. 

After  the  removal  of  the  stitches  the  wound  is  cleansed  with  a  dis- 
infectant, and  the  new  dressing  is  applied.  Whereas  all  hernias  recently 
operated  on  require  support  to  the  region  for  several  weeks,  it  is  best  to 
keep  the  wound  protected  with  the  dressing,   even  though   there  may  be 


5 
6 


PLATE   XXIII. 

Incisions. 
I.  For  diaphragmatic  hernia.  2.  "Supra"  umbilical.  3.  "Para"  umbili- 
cal. 4.  "Sub"  umbilical.  5.  For  ventral  hernia  following  supra  pubic  cys- 
lOtomy.  6.  For  inguinal,  downward  curve  (Fowler).  7.  For  inguinal,  up- 
ward curve  (Ferguson).  8.  For  hernia  following  gall  bladder  operation. 
9.  For  hernia  following  appendectomy.  10.  Straight  incision  for  inguinal 
hernia. 


TREATMENT  OF  WOUNDS  I47 

no  avenue  of  infection  visible,  for  about  three  weeks,  when  fibrous  forma- 
tion is  fully  established. 

Septic  Wounds.  The  infection  of  a  wound  is  either  primary  or  sec- 
ondary, and  the  infection  may  be  superficial  or  deep,  mild  or  severe.  If 
on  the  removal  of  the  first  dressing  the  edges  of  the  wound  and  the  stitch- 
holes  look  angry  and  red,  ?.nd  are  tender  to  touch,  the  wound  is  said  to  be 
infected  superficially.  If  this  occurs  on  the  third  or  fourth  day,  there  may 
be  no  suppuration,  but  stitch-hole  abscesses  are  sure  to  develop  unless 
counteracted  by  treatment,  lliis  treatment  should  be  antiseptic  in  char- 
acter. 

The  inflamed  parts  should  be  irrigated,  preferably  with  bichloride 
of  mercury,  i  in  looo,  or  Harrington's  solution,  and  then  a  wet  compress  of 
gauze  moistened  in  i  in  2000  bichloride,  should  be  placed  over  the  wound 
and  new  dressings  applied.  This  cleansing  and  dressing  of  the  wounds 
should  be  repeated  every  day  for  three  days,  when  it  will  be  found  that 
the  inflammation  has  been  subdued.  If  the  dressing  is  not  changed  until 
between  the  fourth  and  the  eighth  day,  and  if  stitch-hole  abscesses  are  pres- 
ent, cultures  should  be  made  and  the  nature  of  the  infection  determined. 
The  treatment  to  be  carried  out  under  such  circumstances  is  the  same  as 
that  already  mentioned,  with  the  exception  that  when  the  infection  is 
severe  the  irrigation  and  dressing  may  have  to  be  done  twice  a  day  until 
suppuration  has  ceased,  then  once  a  day  until  granulation  tissue  is  healthy, 
after  which  no  antiseptics  should  be  used  on  the  healthv  granulating  sur- 
face. 

If  this  superficial  infection  is  found  to  extend  deeply  into  the  wound, 
it  should  be  opened  sufficiently  to  allow  free  drainage,  and  the  wound 
packed  with  iodoform  gauze.  If  the  suppuration  is  present  for  some  time, 
then  the  antiseptic  solution  used  for  irrigation  should  be  changed.  If  a 
sublimate  solution  is  used  in  a  strength  of  from  i  in  icoo  to  i  in  5000,  and 
is  continued  for  several  days,  an  intolerable  burning  pain  will  often  arise 
in  the  wound.  Then  the  irrigating  solution  should  be  changed  to  an  iodine 
or  normal  salt  solution. 

The  temperature  of  the  irrigating  fluid  should  not  be  less  than  105° 
F.  and  not  more  than  115°  F. 

There  are  many  other  antiseptic  solutions  that  can  be  used,  such  as 
lysol,  permanganate  of  potash,  carbolic  acid,  salicylate'  of  soda,  the  silver 
salts,  etc. 

Wounds  that  are  deeply  infected  from  a  primary  source  usually  give 
rise  to  constitutional  symptoms  between  the  third  and  fourth  day.  There 
may  be  a  temperature  ranging  from  99°  F.  to  103°  or  104"  F.,  with  chilly 
sensations,  accompanied  by  pain,  tenderness,  rapid  pulse,  etc.  If  at  the 
end  of  seventy-two  hours  these  symptoms  are  present,  there  is  a  clear  in- 
dication for  inspection  of  the  wound,  and  if  there  is  any  undue  promi- 
nence or  tenderness,  the  deep  wound  must  be  explored  with  all  aseptic 
and  antiseptic  precautions,  and  if  an  accumulation  is  found  the  same  should 
be  drained. 

If  the   infection   is   saphrophytic   in   character   it   subsides   under   this 


148  TREATMENT  OF  WOUNDS 

treatment  within  a  couple  of  davs.  But  the  pyogenic  and  pathogenic  or- 
ganisms are  harder  to  kill.  If  the  infecting  germ  is  the  streptococcus, 
every  effort  should  be  put  forth  to  prevent  a  dangerous  blood  infection  by 
frecjuent  or  continued  irrigation  of  the  wound.  xA.nd  the  entire  wound 
should  be  laid  wide  open  from  top  to  bottom,  removing  all  the  stitches  and 
treating  it  most  uncompromisingly.  Any  extension  of  the  inflammation 
into  the  cellular  tissue  should  at  once  be  followed  and  drained.  If  lymphan- 
gitis arises,  local  applications  of  glycerine  and  ichthyol,  10  per  cent,  iodine, 
Crede  ointment,  or  formalin  and  glycerin,  may  be  applied.  If  the  con- 
stitutional symptoms  continue,  the  administration  of  the  antiseptic  strep- 
tococcic serum  may  be  considered. 


CHAPTER  XV. 

COMPLICATIONS  INCIDENT  TO  THE  RELIEF  OF  HERNIA. 

SHOCK. 

After  an  operation  for  the  radical  cure  of  hernia,  shock  is  not,  in  the 
usual  run  of  cases,  a  common  complication.  In  large  incarcerated  hernias, 
whether  inguinal  or  umbilical,  where  the  bowel  sometimes  has  to  be  handled, 
adhesions  liberated  or  the  abdomen  explored,  more  or  less,  shock  must 
be  expected,  and  it  is  sometimes  present  to  a  dangerous  degree.  A  series 
of  shocks  are  caused  on  the  operating  table  b}-  the  occasional  rough  handling 
or  tearing  of  the  structures  by  the  operator  and  his  assistants.  Surgical 
literature  is  replete  with  "shock" — (descriptions  of) — but  there  are  so 
many  misconceptions  of  shock  that  scientific  and  practical  data  are  diffi- 
cult to  obtain.  The  Cartwright  prize  essay  for  1897,  by  G.  W.  Crile,  of 
Cleveland,  "An  Experimental  Research  into  Surgical  Shock,"  is  the  best 
on  the  subject.     Every  surgeon  should  read  it. 

Any  form  of  shock  is  due  to  injury  or  insult  to  some  part  or  to  the 
whole  of  the  body.  In  hernia  operations  it  occurs  either  during  or  after 
the  operation  and  sometimes  so  suddenly  and  so  rapidly  increasing  in 
gravity  as  to  be  called  a  sudden  collapse.  The  term  collapse  (impending 
dissolution)  means  more  danger  than  is  ascribed  to  shock.  It  not  infre- 
quently comes  on  at  the  termination  of  a  major  operation,  several  min- 
utes after  the  withdrawal  of  the  anesthetic  and  at  about  the  time  that  the 
patient  should  begin  to  revive.  It  really  seems  as  if  when  all  reflexes  are 
being  aroused  the  afferent  impulses  take  on  an  avalanche  action  and  tend 
to  overpower  all  efferent  response. 

The  causes  of  shock  are  undue  traumatism  while  operating;  protracted 
anesthetic ;  exposure  of  the  intestines  and  omentum ;  and  prolonged  oper- 
ation. Hemorrhage  is  a  very  rare  cause  of  shock  in  this  class  of  work, 
because  important  vessels  are  not  severed  by  careful  operators. 

Shock  is  more  marked  in  operations  for  the  cure  of  umbilical  and 
ventral  hernia  than  in  those  for  the  inguinal  or  femoral  variety.  This 
observation  is  supported  by  the  experiments  of  Crile.  If  in  abdominal 
procedures  the  omentum  is  made  to  cover  the  viscera  less  shock  occurs. 
When  a  person  is  being  ojjeraled  on  and  the  pulse  increases  rapidly  (15  to 
30  beats)  the  skin  gets  pale  and  cold,  blood  in  the  wound  becomes  more 
venous  in  character  than  normal,  with  a  decrease  of  the  temperature,  shock 
may  be  said  to  be  established. 

Shock  on  the  operating  table  must  be  differentiated  from  chloroform 
asphyxia.  In  the  latter  the  onset  is  sudden,  respirations  cease,  the  pulse 
early  become  imperceptible,  the  face  assumes  a  pale-yellowish  hue  and  the 


150  COMPLICATIOXS    IXCIDEXT    TO    THE    RELIEF    OF    HERXIA 

pupils  dilate.  By  lowering  the  head,  pulling-  out  the  tongue,  compressing 
the  chest  wall  for  fully  one  minute  before  inhalation  is  allowed  to  occur, 
thus  expelling  the  chloroform  from  the  respiratory  tract,  and  then  by  in- 
ducing artificial  respiration,  the  efifect  is  soon  overcome,,  and  the  patient 
begins  to  struggle. 

The  condition  of  the  patient  is  often  rendered  more  serious  by  the 
improper  establishment  of  a}-lificial  respiration.  The  ver}-  first  effort  "o  be 
made  is  to  force  an  inspiration  by  raising  the  arms  above  the  head, — the 
column  of  uninhaled  chloroform  in  the  trachea  and  bronchial  tubes  is 
forced  into  the  circulation  and  the  poisoning  thereby  deepened.  The  chest 
should  first  be  compressed  for  a  minute,  then  the  arms  slowly  raised,  tak- 
ing the  time  required  to  count  deliberately  up  to  three,  and  then  hold  the 
upper  extremities  above  the  head  with  an  upward  and  outward  extension, 
counting  i,  2,  3,  and  again  bring  the  arms  flexed  at  the  elbows  down  forci- 
bly on  the  costal  arches  which  sends  the  air  out  of  the  lungs  with  a 
whizz;  then  again  count  i,  2,  3,  and  so  on.  Artificial  respiration  is  thus 
continued  until  reaction  sets  in.  If  artificial  respiration  is  carried  on  too 
rapidly  the  respiratory  center  becomes  more  than  satisfied  with  oxygen 
and  respiration  is  suspended. 

In  overdoses  of  chloroform  not  considered  serious,  the  passing  of 
the  index  finger  behind  the  epiglottis  and  raising  the  larynx  up  and  for- 
ward will  quickly  induce  respiratory  acts.  In  many  cases  this  is  all  I  have 
done  to  re-establish  respiration. 

One  dram  of  ether,  given  hypodermically,  is  a  powerful,  safe  and 
useful  stimulant  for  resuscitation  from  chloroform  poisoning,  and  the  ether 
is  usually  at  hand.  When  ether  is  the  anesthetic  administered  an  additional 
quantity  given  hypodermically  would,  of  course,  do  harm. 

Shock  is  often  delayed  in  very  major  operations,  operations  performed 
svviftly  and  well,  v^diere  all  means  were  taken  to  forestall  a  knockout  on  the 
table  with  the  hope  of  saving  a  life.  There  is  in  every  person  a  limitation  to 
the  amount  of  bowel  that  can  be  removed  with  impunity,  and  the  number 
of  adhesions  that  may  be  broken  down  with  safety  to  the  patient's  life.  The 
extent  of  work  done  in  a  given  lime  varies  vastly  with  different  surgeons, 
and  this  is  no  mean  factor  in  causing  primary  and  secondary  shock. 

Crile,  in  his  experiments,  noticed  that  "On  incising  the  skin  over  the 
testes  there  was  frequently  a  considerable  fall  in  the  pressure  in  keeping 
with  the  phenomena  attending  injury  of  this  organ."  And  again,  "'All 
the  observations  tend  to  show  that  the  more  specialized  and  abundant  the 
nerve  supply  to  a  part  the  more  will  it  contribute  to  the  production  of  shock 
when  subjected  to  injury." 

Cutting  through  muscles  and  fascia  has  very  little  or  no  eft'ect  on 
the  heart.  On  reaching  the  peritoneum,  contact,  touch,  or  tear  of  it 
causes  more  or  less  disturbance  indicative  of  shock.  "The  more  severe 
the  injury,  the  greater  extent  of  contact  and  exposure,  the  more  quick  and 
rapid  was  the  decline  of  the  blood-pressure."        (Crile.) 

In  regard  to  the  testicles,  Crile  showed  by  experiments  that  "Cutting 


8 
9 


10 
11 
12 


_    5 


PLATE  xxn; 

Incisions. 

I.  Epigastric  hernia.  2.  For  hernia  after  nephrotomy.  3.  For  lumbar 
hernia.  4.  Semilunaris  hernia.  5.  For  direct  inguinal.  6.  For  obturator. 
7.  Ventral  (rectus  muscle).  8.  aLongitudinal.  9.  bTrans verse  (Mayo). 
10.  For  ventral.  11.  bOblique  (Ferguson)  for  femoral  hernia;  12.  aLongi- 
tudinal (Ochsner)   for  femoral  hernia. 


COMPLICATIONS    INCIDENT    TO   THE   RELIEF   OF    HERNIA  1 53 

the  testicles,  spermatic  cord,  tunica  vaginalis,  caused  in  most  instances  a 
fall  in  the  blood-pressure  appearing  after  a  short  interval." 

Latent  or  delayed  shock  is  the  depressed  condition  that  occurs  some 
time  after  the  operation.  What  probably  has  happened  is  that  a  ligature 
has  slipped  and  hemorrhage  is  taking  place.  This  is  not  considering  men- 
tal shock  caused  by  bad  news,  etc. 

Treatment. — -Strychnin  sulphate,  gr.  i-io  to  1-30,  should  be  given 
every  i,  2,  3,  or  4  hours,  according  to  the  urgency  of  the  case.  It  raises 
and  sustains  the  blood  pressure. 

Artificial  respiration  is  demanded  to  supply  oxygen  to  the  blood  and 
to  stimulate  the  heart  to  contract.  If  the  patient  becomes  restless  and 
shock  continues,  gr.  1-16  of  morphine  and  gr.  1-120  of  atropine,  hypoderm- 
ically,  every  six  or  eight  hours,  acts  splendidly  by  regulating  the  reflexes 
and  calming  the  patient,  while  gr.  ^  of  morphine  would  likely  kill  the 
patient. 

Nitroglycerine,  gr.  1-150,  every  two  hours,  is  of  service  as  a  rapid 
cardiac  stimulant.  Camphor  and  musk  I  have  found  of  very  little  use. 
It  is  true  I  have  only  employed  them  when  other  drugs  had  failed,  and 
in  only  twelve  cases  (not  hernia).  Remember  to  apply  heat,  but  do  not 
burn  the  patient.  Boiling  water  poured  into  cans  or  rubber  bags  and 
placed  near  the  skin  of  the  person  will  surely  burn.  The  temperature  of 
the  water  should  be  about  120°  F.  In  one  instance  (pylorectomy  done  in 
1893)  I  kept  my  patient  on  a  hot  water  rubber  bed  for  seven  days.  This 
aided  materially  in  preventing,  and  at  the  same  time  in  treating,  the  shock 
which  was  well  pronounced.  Dry  rubbing  of  the  skin  is  of  benefit,  but 
rubbing  with  alcohol  does  harm.  The  foot  of  the  bed  should  be  raised 
and,  if  necessary,  the  lower  extremities  should  be  bandaged.  If  shock 
is  accompanied  by  hemorrhage  1000  c.  c.  of  normal  salt  solution  should 
be  given  beneath  the  skin  and  repeated  every  four,  six  or  eight  hours 
p.  r.  n.  If,  however,  hemorrhage  is  not  an  element  in  the  production  of 
the  shock  500  c.  c.  is  about  the  proper  quantity.  If  very  rapid  action  is 
demanded  the  saline  solution  may  be  administered  into  a  vein  while  the 
patient  is  still  on  the  operating  table.  The  temperature  of  the  normal  salt 
solution  is  important.  It  should  not  be  less  than  110°  F.  and  not  higher 
than  118°  F.  as  it  enters  the  circulation.  The  temperature  of  the  water 
in  which  the  flask  containing  the  normal  salt  solution  stands  should  be 
kept  at  120°  F.,  which  will  insure  the  proper  temperature  for  the  salt  solu- 
tion. According  to  the  mode  of  administration  it  loses  i,  2,  or  3  degrees 
before  it  enters  the  blood. 

If  salt  infusion  is  given  at  a  temperature  of  100°  to  103°  F.,  as  is 
often  recommended,  shock  is  invariably  deepened.  "The  combination  of 
and  frequently  repeated  hypodermic  injections  of  strychnine,  together  with 
saline  infusion  is  most  effectual."      (Crile's  experiments.) 

Predigested  nutrient  enemas  should  be  administered  without  delay 
(milk,  egg,  coffee,  brandy,  etc.),  every  six  hours.  It  is  well  to  remember 
that  in  shock  absorption  by  the  stomach  does  not  take  place  to  a  great 
degree,  and  for  this  reason  only  teaspoonful  doses  of  hot  water  should  be 


154  COMPLICATIONS    INCIDENT   TO    THE   RELIEF   OF    HERNIA 

injected  about  every  half  hour.     If  the  stomach  is  partly  filled  with  liquid, 
it  should  be  washed  out. 

HEMORRHAGE. 

In  operations  for  the  cure  of  hernia,  hemorrhage,  both  primary  and 
secondary,  may  be  alarming. 

Primary  Hemorrhage.  When  operating  on  hernias,  primary  hemor- 
rhage must  be  guarded  against  carefully,  and  when  it  does  occur  it  must 
be  controlled  absolutely  in  order  to  obtain  ideal  results  from  the  operation. 
The  vessels  that  may  be  injured  and  that  give  rise  to  dangerous  hemorrhage 
when  operating  on  inguinal  hernia  are  the  deep  epigastric  and  iliac  arteries 
and  veins.  Of  course,  it  is  impossible  to  avoid  injuring  the  superficial 
vessels,  but  hemorrhage  from  these  is  controlled  easily  by  means  of  the 
clamp  and  ligature.  In  Fowler's  operation  for  hernia  the  deep  epigastric 
vessels  are  exposed,  clamped,  cut  and  tied,  which  last  must  be  done  very 
carefully  and  securely.  Any  injury  to  these  vessels  produces  quite  a  flow 
of  blood  and  no  time  must  be  lost  in  checking  the  same. 

In  hernias  of  long-standing,  where  there  is  a  bulging  out  of  the  en- 
'X  tire  inguinal  region,  the  deep  epigastric  vessels  sometimes  override  the 
\     sac.     They  are  then  tied  deliberately  and  cut. 

Hemorrhage  from  the  vessels  of  the  cord,  no  matter  how  slight  it 
may  be,  should  be  checked  by  the  application  of  the  ligature.  If  the  iliac 
vessels  are  grasped  carelessly  by  the  needle,  or  if  they  are  torn  while  dis- 
secting out  the  sac,  the  injur}'  is  a  dangerous  one  even  though  it  is  the  re- 
sult of  a  blunder.  In  twenty-five  years  I  have  seen  two  such  cases  in  con- 
sultation. 

In  large  hernias  of  long  standing',  occurring  in  persons  who  have 
very  stiff  arteries,  persistent  oozing  may  take  place  and  unless  the  wound 
is  drained  with  silkworm  gut  the  blood  will  accumulate  in  the  deeper  tis- 
sues and  probably  cause  serious  disturbance  later  on.  In  cases  in  which 
it  is  necessary  to  incise  the  scrotal  tissues,  hemorrhage  is  quite  likely  to 
prove  troublesome.  It  must  be  checked  before  the  wound  is  closed,  and  a 
capillary  drain  had  best  be  inserted. 

When  it  is  necessary  to  liberate  a  strangulated  hernia  we  no  longer 
do  the  old-fashioned  herniotomy,  using  a  knife  and  cutting  on  a  grooved 
director.  Wounding  of  the  vessels  in  the  region  of  a  femoral  hernia  is 
an  occasional  accident.  The  vessels  that  are  endangered  most  during  an 
operation  on  a  femoral  hernia  are  the  long  saphenous  vein,  the  femoral 
vein,  and  the  obturator  artery  when  it  pursues  an  abnormal  course  along 
the  outer  border  of  Gimbernat's  ligament.  When  the  obturator  artery  is 
injured  it  is  advisable  at  once  to  sever  Poupart's  ligament  near  the  pubic 
spine,  exposing  the  artery  at  or  near  its  origin.  Let  me  say,  however, 
that  Gimbernat's  ligament  may  be  severed  carefully  with  the  sharp  point 
of  the  scalpel  on  its  under  surface  so  as  to  avoid  the  obturator  artery. 

When  operating  for  the  relief  of  an  obstruction  of  an  obturator  hernia, 
the  obturator  vessels  are  in  danger  of  being  wounded.  After  passing 
through  the   pectineus   muscle   and   having  exposed   the   hernia,   the   con- 


2. 


PLATE  XXV. 
Macewen's  Operation  for  Inguinal  Hernia. 


COMPLICATIOXS    IXCIDEXT    TO   THE   RELIEF    OF  .HERNIA  I57 

striction  is  most  safely  severed  without  injury  to  the  vessels  by  cutting 
upward.  They  are  injured  occasionally,  but  by  retracting  the  wound  edges, 
which  can  be  done  in  a  moment,  the  vessel  may  be  caught  and  ligated. 

Two  sets  of  vessels  may  be  wounded  when  operating  on  an  ischiatic 
hernia,  (a)  the  gluteal  vessels  when  the  hernia  protrudes  through  the 
great  sciatic  notch  above  the  pyriformis  muscle,  and  (b)  the  sciatic  ves- 
sels when  the  hernia  protrudes  from  beneath  this  muscle. 

Secondary  Hemorrhage.  Sometimes  it  is  extremely  difficult  to  rec- 
ognize a  secondary  hemorrhage,  because  there  are  so  many  degrees  thereof, 
and  evidence  of  its  presence  is  dependent  on  the  source  and  rapidity  of  the 
bleeding.  In  nearly  every  instance  the  hemorrhage  is  the  result  of  some 
error  in  the  technic.  such  as  tying  a  vessel  improperly  or  too  loosely;  pull- 
ing the  ligature  after  it  has  been  applied;  severing  the  ligature  too  close  to 
the  knot ;  leaving  too  short  a  stump  of  tissue  outside  of  the  ligature ;  trust- 
ing too  large  a  vessel  to  angiotrypsic  pressure ;  extensive  capillary  oozing, 
or  the  tissue,  if  edematous,  may  shrink  so  that  the  ligature  no  longer  com- 
presses the  vessels.  These  causes  of  secondary  hemorrhage  mav  be  met 
with  in  connection  with  the  ablation  of  a  gangrenous  omentum.  When  the 
blood  becomes  overcharged  with  normal  saline  solution,  or  when  the  solu- 
tion is  administered  too  hurriedly  or  in  too  large  quantities,  serious  and 
sometimes   uncontrollable   secondary   hemorrhage   may   occur. 

The  best  means  of  controlling'  capillar}-  oozing  from  a  loop  of 
bowel  that  has  been  strangulated  but  possesses  suiiticient  vitalitv  to  permit 
of  its  being  returned  within  the  abdomen,  is  to  dust  its  surface  freelv  with 
sterile  subgallate  of  bismuth.  This  powder,  which  is  slightly  antiseptic 
and  slightly  astringent,  checks  the  oozing  from  raw  surfaces  on  the  perjj 
toneum  anywhere,  and  prevents  adhesions  from  taking  place. -Tt  favors 
rapid  coagulation  of  the  blood,  and  the  feeble  astringent  action  which  it 
possesses  is  not  harmful  to  the  tissues. 

Fine  sewing  with  catgut,  using  figure-of-eight  or  cuxular  stitches  on 
the  raw  and  bleeding  surface,  is  an  excellent  means  of  checking  hemorrhage, 
where  it  can  be  applied.  It  may  be  utilized  in  cases  of  hemorrhage  from 
the  surface"  of  the  large  bowel,  stomach,  bladder,  liver,  spleen,  and  other 
abdominal  viscera.  It  cannot,  however,  be  applied  successfully  on  the  bleed- 
ing surface  of  a  friable  small  bowel.  The  principal  oozing  points  may  be 
picked  up  superficially  with  adjacent  peritoneum  by  means  of  fine  catgut. 
A  number  of  such  .circular  stitches  may  be  inserted  advantageously,  the  sur- 
face then  being  dusted  over  with  subgallate  of  bismuth. 

If  there  is  a  persistent  oozing  from  a  loop  of  bowel,  or  from  the  omen- 
tum, the  bleeding  surface  may  be  w^rapped  up  in  a  dry  dressing  of  gauze, 
being  first  dusted  with  the  powder,  then  proceeding  with  the  operation. 
When  it  is  time  to  close  the  wound  it  will  usually  be  found  that  the  raw 
surface  that  formerly  bled  is  now  dry.  The  electro-thermo-cautery 
(Downes)  is  an  excellent  hemostat  in  cases  where  it  can  be  applied,  as  on 
the  omentum.  The  actual  cautery  is  practically  useless  for  this  purpose, 
and  so  is  hot  water. 

When  the  pulse   quickens,  the  temperature   falls,  respiration  becomes 


158  COMPLICATIONS    INCIDENT   TO    THE   RELIEF   OF    HERNIA 

labored,  the  skin  and  mucous  membranes  become  pale  and  cold,  and  there 
is  vertigo  and  restlessness,  with  tossing  of  the  arms  and  legs  and  a  desire 
to  get  out  of  l)ed,  it  mav  be  too  late  to  save  the  patient  suffering  from  a 
secondar}-  hemorrhage  or  its  effects.  Never  hesitate,  however,  even  in  the 
face  of  these  signs  of  death,  to  check  the  hemorrhage  and  institute  treat- 
ment to  save  the  life  of  the  paiietit,  because  sometimes  you  will  be  agree- 
ably surprised. 

TEMPERATURE. 

When  complications,  such  as  collapse,  shock,  hemorrhage,  or  death, 
are  impending,  the  temperature,  as  a  rule,  becomes  subnormal.  The  de- 
pressing effect  of  the  anesthetic  cools  off  the  surface  of  the  body.  A  sub- 
normal temperature  occurring  while  the  patient  is  on  the  operating  table 
is  a  sign  of  shock.  If,  after  the  patient  is  placed  in  bed,  the  temperature 
falls  suddenly,  it  is  a  sign  of  hemorrhage.  If  the  temperature  rises  during 
the  course  of  the  operation,  it  is  an  ill  omen.  A  flight  lowering  of  the 
temperature  after  the  operation  and  then  a  gradual  or  even  a  sharp  rise 
may  not  mean  any  complication ;  but  if  the  temperature  does  not  subside  by 
the  third  day,  the  wound  should  be  inspected  and  an  infection  looked  for. 

VOMITING. 

Vomiting  may  be  so  persistent  as  to  demand  attention.  If  the  patient 
vomits  while  taking  the  anesthetic,  it  may  mean,  (a)  food  or  liquids  in  the 
stomach,  or  (b)  an  overdose  of  the  anesthetic.  Whenever  a  semi-conscious 
patient  begins  to  vomit  profusely,  there  is  danger  of  his  being  suffocated 
by  inhalation  of  the  vomitus.     Be  ready  to  open  the  trachea,  if  necessary. 

Nausea  and  vomiting  are  two  great  objections  to  the  use  of  ether 
and  chloroform.  I  recall  operating  on  several  patients  three  or  four  times, 
on  separate  occasions,  who  nearly  died  from  vomiting,  no  matter  what 
anesthetic  had  been  used.  The  ingestion  of  large  amounts  of  liquids  or 
food  soon  after  operations  often  induces  vomiting.  In  such  cases  I  have 
frequently  and  to  great  advantage  allowed  the  patient  to  drink  hot  water 
freely,  with  about  five  grains  of  bicarbonate  of  soda  added  to  each  ounce 
of  water.  If  it  is  retained  the  nausea  soon  ceases;  if  it  is  ejected,  the 
stomach  is  thereby  w^ashed  out.  It  is  difficult  to  make  patients  understand 
that  vomiting  is  increased  b\'  the  drinking  of  liquids,  and  that  drugs  are 
of  no  avail  to  relieve  the  vomiting.  When  vomiting  occurs  in  the  oper- 
ating room,  it  is  a  good  plan  to  wash  out  the  stomach  after  the  operation 
has  been  completed.  I  am  convinced  that  less  stomach  disturbance  follows 
v.'hen  this  is  done,  especially  after  hernia  operations. 

Owing  to  the  strain  to  wdiich  the  stitches  in  the  wound  are  subjected, 
it  is  possible  for  the  wound  to  burst  open.  Some  time  ago  I  operated  on 
a  small  umbilical  hernia,  removed  the  navel,  and  brought  like  structures 
together  with  plain  catgut  (the  supply  of  chromic  catgut  being  exhausted) 
and  silkworm  gut.  through-and-through  stitches  were  inserted  to  insure 
success.  On  the  eighth  day,  contrary  to  orders,  the  silkworm  gut  stitches 
were  removed  and  the   wound  was   dressed.     About  half  an  hour  after- 


COMPLICATIONS    INCIDENT   TO    THE   RELIEF    OF    HERNIA  1 59 

wards  the  patient  began  to  A-omit,  and  she  continued  to  retch  and  strain 
for  about  three  hours,  when  the  entire  wound  burst  open  and  coils  of 
intestine  appeared  beneath  the  dressings.  The  vomiting-  was  induced  by 
the  removal  of  the  stitches  when  the  stomach  was  full  of  food,  and  prob- 
ably was  continued  by  the  irritation  of  the  wound  and  compression  of  the 
intestines  while  they  were  being  forced  through  the  opening.  Re-suturing 
v.4th  silkworm  gut,  without  the  use  of  an  anesthetic,  completely  relieved 
the  condition.     The  lessons  to  be  learned  from  this  case  are  obvious. 

Straining  and  vomiting  are  very  deleterious  to  wounds  made  during 
a  hernia  operation,  even  though  the  field  of  operation  be  well  dressed  and 
strapped  down  with  broad  adhesive  straps.  When  vomiting  persists  for 
twenty-four  hours,  it  is  advisable  to  wash  out  the  stomach  because  a  cer- 
tain degree  of  acute  gastrectasis  may  be  present  which  is  not  easily  over- 
come without  the  assistance  of  a  stomach  tube.  After  washing  out  the 
stomach  no  food  or  liquid  should  enter  it  for  at  least  tvrelve  hours.  Even 
the  holding  of  ice  in  the  mouth  and  gargling  with  water  induces  nausea  and 
vomiting.  In  the  vast  majority  of  cases  the  administration  of  bismuth, 
creosote,  a  few  drops  of  chloroform  or  of  capsicum,  and  iced  champagne 
does  harm.  Persistent  vomiting  after  an  operation  for  strangulated  hernia 
calls  for  stomach  lavage  repeatedly,  and  after  each  lavage  sufficient  mor- 
phine (beginning  with  1-16  grain,  with  1-200-  atropine,  hypodermically, 
and  continually  increasing  the  dose,  if  necessary)  should  be  given  to  con- 
trol stomach  peristalsis.  When  the  bowels  have  been  obstructed  and  then 
handled  by  the  surgeon,  slight  pathologic  changes  and  local  shock  suspend 
peristalsis  for  several  days,  and  the  gastro-intestinal  contents  can  receive 
no  aid  in  passing  through  the  portion  of  the  intestine  whose  function  is 
thus  suspended.  The  consequence  is  that  anything  that  is  forced  into 
the  stomach  is  quite  likely  to  be  forced  back. 

A  stomach  with  residual  contents  after  emesis  should  be  washed  out. 
One  of  the  alarming  signs  in  connection  with  vomiting  is  the  appearance  of 
blood  in  the  vomitus — the  naked  eye  appearance  being  like  coftee.  In 
cases  with  no  residual  contents,  or  blood  in  the  material  vomited,  a  seda- 
tive^ such  as  morphine,  is  indicated  to  allay  action  of  the  stomach,  and 
after  being  washed  out  once  with  a  feeble  solution  of  permanganate  of 
potash,  absolute  rest  should  be  enjoined.  If,  however,  the  stomach  is  dilated, 
the  act  of  vomiting  being  insufficient  to  empty  it,  and  blood  appears  in  the 
ejecta,  the  stomach  must  be  washed  out  at  once,  but  no  morphine  or  other 
sedative  should  be  thought  of,  let  alone  administered,  because  the  dilata- 
tion of  the  organ  would  only  be  increased  and  leakage  of  blood  from  the  cap- 
illaries be  favored.  This  very  condition  is  caused  by  overdosing  with  mor- 
phine a  patient  suffering  from  shock.  It  is  strange,  but  true,  that  even  doc- 
tors suffering  from  the  effects  of  a  major  operation  not  infrequently  prefer 
to  be  relieved  by  morphine  at  the  risk  of  death,  than  to  suffer  and  struggle 
for  life  during  one  night.  Along  with  this  condition  we  usually  find  some 
other  grave  complication,  involving  the  heart,  kidneys  or  liver,  which  car- 
ries the  patient  off. 

Bile  iri  the  ejecta  may  mean  (a)  a  retro-peristalsis  due  to  the  suspension 


l60  COMPLICATIONS    INCIDENT   TO   THE   RELIEF    OF    HERNIA 

of  normal  peristalsis  in  some  portion  of  the  intestines  on  account  of  the 
operation,  or  (b)  when  colicky  pains  are  in  the  abdomen  at  the  same  time 
more  significance  must  be  given  to  the  appearance  of  bile — suspicion  of  ob- 
struction. Should,  however,  bile  and  fecal  matter  be  vomited,  associated 
with  colickv  pains  in  the  abdomen,  obstruction  of  the  bowels  is  almost  sure 
to  exist.  No  time  should  then  be  lost  in  examining  the  wound  in  the  abdo- 
men and  exploring.     Prompt  action  is  a  life-saving  agent. 

When  vomiting  is  associated  with  tympany  only,  paresis  of  the  bowels 
is  present,  and  stimulating  enemata,  hot  turpentine  stupes  over  the  abdo- 
men and  large  doses  of  strychnine  are  indicated,  but  no  morphine  or  any 
sedative.  Associated  with  vomiting  we  sometimes  find  not  alone  tympany, 
but  a  temperature  as  high  as  102°  to  104"  F.,  with  or  without  chilly  sensa- 
tions, chills,  rigors  or  thirst :  Then  peritonitis  is  the  most  likely  cause  of  all 
the  symptoms  and  signs. 

TYMPANITES. 

Nourishment  bv  bowel  should  be  commenced  immediately  after  all 
major  hernia  operations. 

Over-distention  of  the  intestines  with  gas  is  a  complication  no  less  dis- 
tressing to  the  patient  to  endure  than  to  the  surgeon  to  treat.  It  is,  of 
course,  a  sign  of  something  being  wrong.  It  may  arise  after  the  most  sim.~ 
pie  operation  for  hernia  and  greatly  disturb  the  patient  and  all  in  attend- 
ance. If  no  temperature  is  associated  with  it,  and  although  slight,  it  must 
be  treated.  It  is  a  common  complication  of  operations  for  strangulated  her- 
nia, and,  too,  when  the  hernia  was  only  incarcerated.  The  distention  of  the 
abdomen  causes  not  merely  an  extensive  sensitive  feeling  of  the  abdomen, 
coterminous  with  its  boundaries,  due  to  overstretching,  but  also  the  pressure 
on  the  stomach  and  diaphragm  interferes  with  digestion  and  impedes  respira- 
tion, much  to  the  patient's  discomfort. 

Kelly,  of  Baltimore,  has  seen  two  deaths  seemingly  due  to  paralysis  of 
the  diaphragm  caused  by  excessive  tympanites.  The  heart,  kidneys  and 
liver  are  equally  affected  by  tympany,  but  the  heart  and  kidneys  most  mark- 
edly. The  heart  begins  to  palpitate  and  becomes  irregular  in  its  action,  on 
account  of  the  pressure.  Tympanites  alone  is  usually  of  no  serious  signifi- 
cance, no  more  than  is  a  fast  pulse,  fever,  constipation,  or  vomiting,  and 
may  be  relieved  easily,  but  when  associated  with  these  evidences  it  is  one 
of  the  prominent  signs  of  peritonitis.  When  tympany  appears  soon  after  an 
operation  for  hernia  I  look  upon  it  with  grave  suspicion,  for  it  may  indi- 
cate that  the  bov/els  are  obstructed. 

In  extreme  tympany  occurring  within  twenty-four  hours  after  operation, 
which  is  not  relieved  by  a  rectal  tube,  stimulating  enema  and  purgation, 
and  which  causes  vomiting,  no  time  should  be  lost  in  reopening  the  abdomen 
and  searching  for  the  cause.  If  you  wait  for  an  elevation  of  temperature 
your  patient  will  be  beyond  relief. 

I  recollect  traveling  fifty  miles  from  Winnipeg,  in  1887,  in  a  sled,  when 
the  temperature  was  45°  F.  below,  to  reduce  a  strangulated  right  oblique 
inguinal  hernia.     Under  chloroform  anesthesia  the  reduction  was  effected 


PLATE   XXVI. 
Bassini's  Operation  for  Tngminal  Hernia. 


COMPLICATIONS    INCIDENT    TO    THE    RELIEF   OF    HERNIA  IO3 

to  my  own  satisfaction,  and  to  the  apparent  relief  of  the  patient.  Within  an 
hour  I  started  on  my  homeward  journey,  but  when  twent}"  miles  distant  a 
telegram  overtook  me  and  I  had  to  return,  on  account  of  "sudden  bloating" 
and  the  bad  condition  of  the  patient,  who,  by  the  by,  was  at  one  time  a  bare- 
footed schoolmate  of  mine.  Upon  returning  I  immediately  opened  the  ab- 
domen in  the  right  inguinal  region,  and  found  that  the  bowel  and  omentum, 
alihough  Lioth  were  reduced  within  the  abdomen,  were  obstructed  to  a 
considerable  degree.  The  band  was  severed,  the  omentum  and  bowel  lib- 
erated, and  the  wound  brought  together  with  through-and-through  stout  silk 
sutures,  the  best  material  at  hand.  A  life  was  saved  and  a  cure  of  the  hernia 
effected. 

If  no  other  sign  except  tympanites  is  present  after  an  operation,  it  is 
good  practice  to  apply  turpentine  stupes  to  the  entire  abdomen  (one  in 
twenty),  changed  every  half  hour  to  three  hours,  according  to  the  protec- 
tion afforded  to  the  stupes,  care  being  taken  not  to  blister  the  skin. 

Instead  of  using  the  ordinary  rectal  tube,  which,  on  account  of  it5 
size,  gives  rise  to  rectal  contractions  and  discomfort,  I  insist  on  using  a 
No.  8  male  self-retention  bladder  catheter.  It  carries  off  the  gas  and  is 
too  small  to  irritate  the  sphincter  of  the  rectum  so  as  to  cause  it  to  contract. 
The  patency  of  the  catheter  should  be  tested  occasionally  by  forcing  air 
through  it.  A  good-sized  dose  of  castor  oil,  with  the  addition  of  twenty 
drops  of  turpentine,  carries  off  the  effete  material  causing  gas.  For  gas 
pains  we  usually  begin  by  passing  the  rectal  tube ;  that  failing,  we  use  a 
I,  I,  I  enema  (one  ounce  of  glycerine,  one  ounce  of  sulphate  of  magnesia, 
and  one  ounce  of  water).  If  this  fails,  we  double  the  quantities  (2,  2,  2 
enema).  This  not  being  a  success,  an  enema  is  given,  consisting  of  an  alum 
solution,  one  ounce  to  the  gallon.  This  last  has  often  succeeded  when  the 
glycerine  and  magnesium  sulphate  failed. 

The  late  L.  M.  Sweetnam,  of  Toronto,  directed  patients  suffering  from 
tyinpanites  to  assume  the  knee-chest  position  and  then  passed  the  rectal 
tube.  Kelly  says  (op.  cit.,  87)  :  "1  gave  her  complete  relief  by  putting  her 
under  chloroform  and  introducing,  in  the  knee-chest  position,  one  of  my 
long  rectal  specula;  the  bowel  was  collapsed  until  the  speculum  reached  the 
sigmoid  flexure,  when  the  gas  began  to  escape  freely,  and  she  recovered." 

Rather  than  allow  a  patient  to  die  from  tympany  I  have,  under  local 
anesthesia,  performed  an  enterostomy  and  saved  my  patient. 

PAIN. 

The  temperament  of  the  patient  has  mucii  to  do  with  the  amount  of 
pain  complained  of  after  an  operation  for  hernia,  the  iiighly  nervous  suf- 
fering the  most,  and  those  of  a  phlegmatic  nature  the  least.  Self"Control 
enables  a  person  to  endure  any  amount  of  suffering  without  complaint.  The 
most  wonderful  example  of  self-control  in  a  child  I  met  in  the  case  of  a 
boy  one  year  old,  on  whom  I  operated  for  mastoid  suppuration,  referred  to 
me  by  Dr.  J.  C.  Cook.  For  some  time  afterward  he  was  brought  to  the 
hospital  for  dressings.  While  the  packing  was  being  removed,  the  wound 
washed,  etc.,  he  would  tightly  grasp  the  hands  of  the  nurse  and  never  com- 


164  COMPLICATIONS    INCIDENT   TO    THE    RELIEF   OF   HERNIA 

plain,  even  though  the  perspiration  would  roll  off  him.  In  explanation  of 
his  excellent  behavior,  Dr.  Cook  told  me  that  it  was  entirely  due  to  the 
training  he  received  during  the  last  three  months  from  a  nurse  who  makes 
a  specialty  of  training  unruly  children  with  kindness. 

The  pain  resulting  from  a  herniotomy  usually  subsides  in  twenty-four 
to  forty-eight  hours,  and  no  morphine  or  other  anodyne  should  be  given  for 
it.  Pain  of  itself  need  cause  no  alarm,  and  it  often  subsides  after  the  suf- 
ferer is  assured  that  recovery  will  be  faster  if  morphine  is  not  taken.  AMien 
the  pain  disturbs  the  patient  to  the  extent  of  preventing  sleep  at  night  for 
several  hours,  then  toward  morning  I  give  %  grain  of  morphine,  with  1-200 
of  atropine  hypodermically.  After  this  sleep  is  usually  obtained  and  no 
more  is  required  for  at  least  twenty-four  hours. 

There  are  exceptions,  however..  I  have  seen  some  patients  whose  lives 
were  saved  by  morphine.  One  case  comes  to  my  mind  now.  A  man,  whos^ 
cecum  I  removed  suffered  so  severely  from  pain  in  the  right  iliac  region, 
which  was  constant  and  excruciating,  that  he  went  into  a  collapse,  became 
cold,  pale  and  pulseless.  In  this  collapsed  condition  he  complained  of  "that 
awful  pain."  I  then  gave  morphine,  gr.  }i,  hypodermically.  This  eased 
him ;  his  pulse  returned ;  color  returned  to  his  skin,  and  he  felt  well.  In 
four  hours'  time  the  pain  returned  and  he  began  to  get  bad  again,  but  for 
two  hours  thereafter  no  morphine  was  given,  not  until  it  was  clear  to  every- 
body that  he  would  die  if  the  morphine  was  withheld.  After  this  the  mor- 
phine had  to  be  given  regularly  for  four  days.  I  am  convinced  that  the 
morphine  saved  his  life. 

Hyoscine-hydrobromate  acts  well  for  nervous  disturbances  other  than 
severe  pain.  Codeine  should  be  tried  for  the  pain  first.  A  good,  strong, 
kind,  sensible  nurse  can  enable  the  patient  to  gain  self-control  and  practi- 
cally lull  her  or  him  to  sleep,  even  though  suffering.  A  nurse  whose  nature 
runs  counter  to  that  of  the  patient  should  at  once  be  removed,  especially  if 
the  patient  is  nervous  or  hard  to  control. 

SKIN  COMPLICATIONS. 

At  the  time  of  the  operation  the  skin  near  the  rupture  may  be  the  seat 
of  an  abscess,  or  an  abscess  may  have  formed  in  connection  with  strangu- 
lation. Last  year  I  had  to  operate  synchronously  on  a  suppurating  lymphatic 
gland  in  the  groin,  caused  by  truss-pressure,  and  on  a  strangulated  hernia 
on  the  same  side.  The  incisions  were  not  more  than  two  inches  apart,  and 
primar}^  union  of  the  hernial  w.ound  occurred.  I  attributed  this  excellent 
result  more  to  the  method  of  dressing  the  two  wounds  than  to  any  particular 
asepticity  carried  out  at  the  time  of  the  operation.  In  order  to  prevent  in- 
fection of  the  clean  wound,  I  formed  a  long  ridge  about  one  inch  broad  and 
one  inch  high,  extending  midway  between  the  two  wounds,  composed  of 
collodion,  cotton  and  iodoform  powder.  The  cotton  was  first  permeated  with 
the  iodoform  powder  and  then  soaked  in  collodion.  It  acted  as  an  antiseptic 
and  a  mechanical  barrier  to  spreading  contamination. 

In  neglected  and  maltreated  cases  of  strangulated  hernia  the  skin  may 
become  inflamed,  edematous  or  even  gangrenous,   manifested  by  redness, 


COMPLICATIOXS    IXCIDEXT    TO   THE    RELIEF   OF    HERXIA  165 

pitting  on  pressure  and  crepitation.  These  skin  complications  may  follow 
violent  taxis  or  come  on  slowly.  They  usually  bespeak  infection  from  the 
condition  of  the  contents  of  the  hernia.  At  first  the  skin  becomes  tense, 
red  and  tender,  and  finally  edematous,  but  with  the  lapse  of  time  nature  tires 
of  fighting  pathologic  changes,  innervation  ceases  to  register  the  condition 
of  dying  or  dead  structures,  and  toxemia  soon  rules  the  entire  economy: 
then  the  swelling  lessens,  the  pain  practically  ceases,  and  the  patient,  uncon- 
scious of  his  perilous  condition,  sleeps  his  last  sleep.  AVhat  an  object  lesson 
to  the  student  who  was  negligent  in  college  I ! 

Eczema  of  the  skin,  or  a  burn  caused  by  the  application  of  hot  fomen- 
tations, may  complicate  operative  procedures.  The  skin  over  an  umbilical 
hernia  thins  out  and  is  most  liable  to  infection,  sometimes  causing  ulceration 
and  sloughing. 


CHAPTER  XVI. 

COMPLICATIONS  INCIDENT  TO  THE  RELIEF  OF  HERNIA 

(Continued). 

SAC. 

The  sac  is  tense  and  full  of  straw-colored  fluid  at  iirst,  but  as  the  stran- 
gulation becomes  sufficiently  advanced  to  cause  death  of  the  contents  of  the 
sac.  the  fluid  becomes  bloody,  grumous  or  purulent  in  character.  The  sac 
at  the  same  time  becomes  correspondingly  changed  in  color  and  constituency  ; 
it  may  be  inflamed,  ulcerated  and  gangrenous.  In  some  instances  the  sac  is 
ruptured  by  taxis.  The  sac  is  not  infrequently  firmly  adherent  to  surround- 
ing structures,  and  its  contents  are  often  adherent  to  its  inner  aspect,  all  of 
which  must  be  taken  into  consideration  when  dealing  with  it  surgically. 

OMENTUM. 

The  omentum  is  either  free  or  attached  to  the  sac  or  to  the  bowel,  or  to 
both.    It  may  be  inflamed  or  gangrenous  in  strangulated  cases.    . 

BOWEL  COMPLICATIONS. 

The  condition  of  the  strangulated  loop  is  the  most  important  to  observe. 
It  may  be  simply  congested  (Fig.  15),  without  destruction  of  any  of  its 
coats.  In  this  condition  the  peritoneum  is  red  and  smooth,  the  vessels  en- 
gorged to  their  limit.  If  the  small  bowel  is  constricted  the  state  of  conges- 
tion is  of  short  duration,  vv^hile  a  large  bowel  may  remain  congested  for 
several  days  (Fig.  16)  without  permanent  damage  ensuing  to  the  loop. 
Sooner  or  later,  however,  the  bowel  becomes  destroyed  by  inflammation 
(Fig.  17),  ulceration  (Fig.  18),  pressure  atrophy  (Fig.  19),  or  gangrene 
(Fig.  20).  The  more  hernias  I  see  in  consultation,  and  the  m.ore  hernias 
I  reduce  by  taxis,  the  more  I  am  impressed  witii  this  danger.  I  have  prac- 
tically come  to  the  conclusion  that  with  rare  exceptions  taxis  should  no 
longer  be  practised.  As  so  ably  pointed  out  by  Maurice  H.  Richardson,  of 
Boston,  its  dangers  are 

1.  Rupture  or  bruising  of  the  sac  or  intestine. 

2.  Tearing  of  adhesions. 

3.  Reduction  en  bloc. 

4.  Fatal  delay. 

ILEUS. 

Ileus  coming  on  after  operations  for  hernia  may  be  temporary  or  per- 
manent. In  the  former  a  simple  twist  of  a  loop  of  bowel  occurs,  and  when 
peristalsis  begins  it  uncoils  itself  and  the  patient  is  relieved  of  the  colic  and 


COMPLICATIONS    INCIDENT    TO    THE    RELIEF   OF    HERNIA  167 

obstruction.  In  permanent  ileus  the  simple  loop  does  not  straighten  out,  or 
a  loop  becomes  obstructed  in  one  of  many  ways,  such  as  by  a  kink  and  ad- 
hesion at  an  acute  angle,  coils  adherent  to  coils  and  bowel  to  raw  surfaces, 
or  a  loop  gets  behind  an  adhesion,  or  through  a  hole  in  the  omentum.  It 
sometimics  happens  that  the  vomiting  due  to  the  anesthetic  forces  a  loop  of 
bowel  into  another  hernial  opening  and  strangulation  occurs.  Such  an  in- 
stance occurred  in  my  practice.  I  operated  in  the  forenoon  on  a  woman,  53 
years  of  age,  for  a  strangulated  right  inguinal  hernia.  She  vomited  furiously 
in  the  middle  of  the  afternoon,  when  she  screamed  and  told  the  nurse  that 
her  intestines  were  down  again,  and  so  persistent  was  she  about  it  that  I 
was  called  hastily.  Upon  removing  the  dressings,  a  tense  femoral  hernia 
was  very  prominently  present.  She  then  told  us  that  the  rupture  would 
sometimes  come  down  on  the  thigh,  but  usually  the  bulging  was  higher  up. 
I  used  taxis  in  vain,  but  only  for  a  short  time,  just  before  operating.  Even 
in  this  short  time  there  was  fluid  in  the  sac,  and  the  small  bowel,  which  it 
contained,  was  intensely  congested,  much  more  so  than  the  small  bowel  and 
omentum  found  in  the  inguinal  hernia,  although  strangulated  for  about 
twxlve  hours. 

The  usual  clinical  picture  of  ileus  is  that  of  distress  and  suffering.  The 
patient  usually  knows  that  his  bowels  are  obstructed  and  can  point  out  the 
exact  spot  where  the  pain  began  and  where  it  has  repeatedly  returned  in 
paroxysms  every  two  or  three  minutes  since  then.  Nausea  and  vomiting 
are  distressing  from  the  beginning  of  the  pain.  The  patient  first  vomits  the 
stomach  contents,  then  bile,  and  finally  the  contents  of  the  small  intestines. 
The  abdomen  is  flaccid  at  first,  except  the  region  of  localized  pain ;  here  it 
is  tumefied  and  tender  on  pressure,  and  as  the  pain  returns  the  abdominal 
wall  here  becomes  more  and  more  tense  and  rises  like  a  ball,  and  has  the  feel 
of  a  semi-solid  tumor.  It  is  not  manv  hours,  however,  before  the  bowels 
become  exhausted,  dilated  proximal  to  the  stricture,  and  the  abdomen  be- 
comes generally  swollen,  tympanitic  and  tender. 

URINARY  BLADDER. 

Irrespective  of  hernias  of  this  viscus  complications  aitecting  the  bladder 
are  liable  to  arise  in  the  course  of,  or  following,  operations  for  the  cure  of 
inguinal,  femoral  and  ventral  hernia.  Retention  of  urine  is  a  very  frequent 
complication  following  any  operation  done  in  the  vicinity  of  the  bladder. 
This  is  easily  corrected  by  means  of  the  catheter  and  by  altering  the  reaction 
of  the  urine,  giving  alkalies,  as  is  usually  indicated. 

In  operations  done  for  the  relief  of  the  direct  form  of  inguinal  hernia, 
the  bladder,  on  account  of  its  close  attachment  to  the  peritoneum  in  this  re- 
gion, is  likely  to  be  partly  extruded  with  the  hernia ;  indeed,  a  portion  of  the 
bladder  may  form  part  of  the  sac  wall.  It  is  in  conditions  like  this  that  the 
bladder  is  likely  to  be  injured  during  the  operation.  I  have  seen  this  viscus 
opened  by  accident,  and  in  one  case,  seen  in  consultation,  a  portion  of  the 
bladder  had  been  tied  off  with  the  sac,  leaving  a  urinary  fistula  which  had 
to  be  remedied  by  a  second  operation. 

It  is  mv  belief  that  hernia  of  the  bladder  in  the  inguinal  or  femoral  re- 


l68  COMPLICATIONS    INCIDENT   TO   THE    RELIEF   OF    HERNIA 

gion  is  exceedingly  rare,  and  that  many  of  the  cases  that  have  been  report- 
ed as  instances  thereof  are  really  instances  where  the  bladder  has  been 
dragged  into  the  field  of  operation.  It  is  a  fact  that  surgeons  who  have  the 
greatest  experience  in  this  work  meet  with  fewer  hernias  of  the  bladder 
than  do  those  whose  experience  is  limited. 

C.  B.  Lockwood  (Trans.  Loud.  Clin.  Soc,  Vol  XXXI)  reports  a  case 
of  incomplete  inguinal  hernia  on  the  left  side.  Four  months  previously, 
while  operating  on  the  opposite  side  for  hernia,  another  surgeon  had  opened 
a  fingerlike  extension  of  the  bladder  which  was  closed  with  sutures.  Later 
two  phosphatic  stones  which  had  formed  on  the  sutures  were  removed  by 
lithotrity. 

Verhoef  (Jour,  de  Chir.  et  Annales  de  la  Soc.  Beige  de  Chir.,  No.  2, 
1903)  reported  two  cases  of  accidental  wounding  of  the  bladder  during 
operations  for  hernia.  In  one  of  the  cases  a  portion  of  the  bladder  was  in 
the  sac ;  in  the  other  it  was  not. 

J.  B.  Harvie  (American  Medicine,  April  4,  1903)  reported  a  case  in 
which  the  entire  bladder  was  found  in  the  hernial  sac.  Before  operation  it 
was  thought  that  the  condition  was  one  of  strangulated  hernia  complicated 
by  hydrocele.  The  upper  part  of  the  mass  was  very  tender  to  touch.  The 
patient  had  had  a  reducible  hernia  for  ten  years,  but  had  never  worn  a 
truss.  The  hernia  became  irreducible  during  an  unsuccessful  attempt  to 
evacuate  the  bowel.  Attempts  at  urination  were  frequent  from  this  time  on, 
but  only  a  few  drops  of  urine  were  passed  at  a  time.  Subsequently  all  the 
symptoms  of  a  strangulated  hernia  appeared.  When  the  sac  was  opened 
about  seven  inches  of  gangrenous  intestine  were,  found  and  resected,  the 
anastomosis  being  made  with  a  Murphy  button.  A  small  opening  made  in 
the  gangrenous  mass  showed  it  to  be  the  bladder.  Considerable  difficulty 
was  experienced  in  reducing  this  organ,  but  it  was  finally  accomplished. 

In  ventral  hernias  the  bladder  occasionally  has  been  found  to  protrude 
immediately  above  the  pubic  bone,  a  position  in  which  it  is  extremely  likely 
to  be  injured  during  the  operation. 

A  urinary  fistula  may  result  from  injury  of  the  bladder  wall  made 
during  an  operation  for  hernia.  I  have  had  occasion  to  close  two  such  fis- 
tulas, one  in  the  suprapubic  and  the  other  in  the  inguinal  region. 

Cystitis  may  follow  hernia  operations,  although  it  is  in  no  way  the 
result  of  this  particular  operation.  When  it  does  occur,  the  treatment  us- 
ually employed  for  this  condition  should  be  carried  out. 

INJURIES  OF  THE  CORD. 

When  the  vessels  of  the  cord  are  accidentally  injured,  the  testicle 
is  likely  to  become  congested  and  hyperplastic,  eventually  undergoing  atro- 
phy.    The  gland  may  also  become  gangrenous. 

Even  when  the  vas  deferens  is  injured  it  is  not  always  necessary  to  re- 
move the  testicle.  In  the  fall  of  1897,  while  operating  for  the  relief  of  a 
strangulated  right-sided  hernia,  I  injured  the  vessels  of  the  cord  to  such  an 
extent  that  castration  was  the  only  recourse.  This  operation  was  done  in 
a  kitchen,  at  about  two  o'clock  in  the   morning,  with  a  very  poor   light. 


PLATE   XXVII. 

Kocher's  Operation  for  Inguinal  Hernia — second  step. 

(Saunder's  Medical  Hand  Atlas.) 


COMPLICATIONS    INCIDENT    TO    THE    RELIEF   OF    HERNIA  I7I 

Otherwise  it  would  not  have  been  possible  to  have  produced  such  an  extensive 
injury.  In  another  case  I  injured  the  vas  deferens  while  operating  for  a 
non-descended  testicle  and  hernia,  but  I  did  not  think  it  necessary  to  re- 
move the  testicle  on  this  occount.  The  outcome  of  the  case  justified  the 
decision. 

COMPLICATIONS  INVOLVING  THE  TESTICLE. 

Atrophy  of  the  testicle  has  occurred  much  more  often  after  Halsted's 
operation  for  oblique  inguinal  hernia  than  after  any  other  method  of  pro- 
cedure. In  sixty-one  cases  this  complication  occurred  ten  times  (16.39  P^^ 
cent.).  Retraction  of  the  testicle  occurred  four  times  in  269  cases  (1.5  per 
cent. ) .  I  have  had  two  cases  of  retraction  of  the  testicle  after  Bassini's  op- 
eration. In  another  case  gangrene  of  the  testicle  followed  removal  of  the 
vas  deferens.     In  both  the  cases  of  retraction  of  the  testicle  the  gland  even-  / 

tually  returned  to  the  scrotum.     In  three  of  Bloodgood's  cases  referred  to  I 

above  the  testicle  returned  to  the  scrotum.  \ 

I  encountered  one  case  of  atrophy  of  the  testicle  following  an  extensive  \ 

suppuration  of  the  glands  in  the  groin,  which  had  extended  to  the  cord.  In 
these  cases  there  w^as  not  a  hernia  present. 

Hydrocele  of  the  tunica  vaginalis  testis  has  occurred  in  10  per  cent,  of 
the  cases  following  Halsted's  operation,  where  the  vas  was  removed. 

SECONDARY  WOUND  SECRETION. 

I  have  met  with  this  complication  in  operations  for  the  cure  of  inguinal, 
femoral  and  extensive  ventral  hernias.  This  complication  can  be  obviated 
easily  by  seeing  to  it  that  no  dead  spaces  are  left  when  the  wound  is  being 
sutured,  and  by  the  proper  application  of  the  primary  dressing.  In  large 
hernias  where  a  sac  has  been  removed  from  within  the  scrotum  and  no 
drainage  is  inserted,  the  scrotum  is  liable  to  be  filled  with  a  secondary 
wound  secretion.    This  is  prevented  by  drainage  with  silkworm  gut. 

In  performing  extensive  plastic  operations  for  the  reUef  of  hernia  any- 
where in  the  abdominal  wall,  dead  spaces  are  very  likely  to  be  left.  The 
surgeon  must  use  his  judgment  in  deciding  when  and  when  not  to  drain  in 
order  to  prevent  secondary  wound  secretion.  When  it  does  occur,  the  fluid 
should  be  withdrawn  at  once,  because  its  presence  in  the  tissues  predisposes 
to  infection. 

INFECTION. 

Infection  has  been  thoroughly  described  in  previous  chapters,  so  it  will 
not  be  necessary  to  take  up  this  subject  extensively  at  this  time. 

Infection  should  not  occur  more  frequently  than  in  one  per  cent,  of  the 
cases.  Before  the  use  of  rubber  gloves  infection  did  occur  in  about  teti  per 
cent,  of  the  cases.  Halsted  reported  42  cases  out  of  446  (9.5  per  cent.).  By 
the  use  of  rubber  gloves  the  occurrence  of  infection  was  reduced  to  about  1.8 
per  cent.  In  looking  over  my  own  statistics,  and  those  of  other  surgeons,  I 
find  that  they  compare  favorably  with  those  of  the  Johns  Hopkins  Hospital. 
During  1902  and  1903,  at  the  Heidelberg  clinic,  31  cases  of  infection  oc- 
curred in  198  cases  (15.6  per  cent.). 


172  COMPLICATIONS    INCIDENT   TO   THE    RELIEF   OF    HERNIA 

PERITONITIS. 

Trauniatic  Reaction  or  Repair.  In  performing  an  operation  for  the 
cure  of  hernia,  the  peritoneum  is  ahvays  opened  and  handled,  and  thereby 
it  is  subjected  to  the  compHcations  caused  by  trauma  and  by  bacterial  in- 
vasion. Strangulated  hernia  carries  its  own  infection  with  it,  and  if  not 
relieved  sooner  or  later,  the  occurrence  of  peritonitis  is  inevitable,  local  or 
general,  or  both.  Until  such  time  when  a  clearer  distinction  between  repair 
(traumatic  or  plastic  peritonitis)  and  a  disease  (peritonitis)  caused  by  bac- 
teria is  generally  adopted.  I  am  constrained  to  uphold  the  modern  concep- 
tion of  the  disease,  viz.,  that  germs  are  the  cause  of  peritonitis. 

It  is  commonly  stated  in  textbooks  that  the  peritoneum  has  great 
powers  of  forming  adhesions.  This  is  a  mistake.  The  normal  peritoneum 
has  no  tendenc}^  to  adhere  to  normal  peritoneum,  or  to  any  raw  surface  unless 
that  surface  is  inflamed.  The  omentum  and  bowels  slide  over  and  lie  in 
contact  with  the  raw  peritoneum  of  the  ovary  month  after  month  and  year 
after  year  without  forming  adhesions.  Why  are  adhesions  within  the  ab- 
domen frequentlv  eradicated  by  merely  breaking  them  down  ?  Simply  be- 
cause raw  surfaces  do  not  always  happen  to  stay  approximated,  on  account 
of  changes  in  locality  of  loops  of  bowel  and  omentum,  but  if  a  raw  surface 
stays  only  a  short  time  in  contact  with  another  raw  surface,  repair  (plastic) 
takes  place.  It  is  just  the  same  as  occurs  after  the  coaptation  of  the  raw 
surfaces  of  any  wound  in  the  soft  parts  of  the  extremities. 

The  redeeming  attributes  of  the  peritoneum  are  its  power  of  rapid  ab- 
sorption and  its  smooth  and  slippery  protection.  Following  exposure 
and  handling  of  abdominal  viscera,  even  in  what  we  call  clean 
cases,  it  is  amazing  the  adhesions  that  may  form  within  a  week,  and  that  are 
demonstrable  when  the  abdomen  has  to  be  opened  for  some  other  compli- 
cation, such  as  the  "vicious  circle"  following  a  gastroenterostomy.  I  have 
seen  new"  adhesions  in  the  form  of  bands  at  the  end  of  three  weeks  (normal 
time  for  their  developm.ent),  and  they  had  to  be  cut  with  a  knife.  At  the 
end  of  one  week  they  are  friable  and  easily  broken  down. 

I  recall  operating  on  two  cases  of  hernia  that  a  few  days  later  demand- 
ed appendectomy.  The  first  patient  was  a  boy,  aged  18,  with  an  uncon- 
trollable (by  truss)  right  oblique  inguinal  hernia.  The  omentum  was  firmly 
adherent  to  the  inner  surface  of  the  sac  and  to  the  small  bowel.  A  portion 
of  omentum  was  amputated  and  the  stump  rolled  within  omental  folds.  On 
the  third  day  (60  hours)  after  the  herniotomy  the  typical  symptoms  of  ap- 
pendicitis developed  suddenly.  I  opened  the  abdomen  (AIcBurney's  incis- 
ion) at  once,  and  found  the  inflamed  and  almost  ruptured  appendix,  but  the 
end  of  the  omentum  and  peritoneum  at  the  site  of  the  herniotomy  presented 
no  adhesions  whatever. 

I  mention  this  case  in  contrast  to  the  second  one.  A  woman,  aged  2)^, 
mother  of  three  children,  had  an  umbilical  hernia  that  had  been  strangu- 
lated for  six  hours.  Bile  and  chyle  were  being  vomited.  Omentum  filled 
the  umbilical  sac  (incarcerated),  while  small  bowel  (strangulated)  occu- 
pied the  sub-umbilical  hernia.    The  abdominal  wall  was  lax.     The  woman 


COMPLICATIONS    INCIDENT    TO   THE    RELIEF   OF    HERNIA  1/3 

was  not  obese.     The  operation  was  neither  difficuh  nor  prolonged,  and  a 
beautiful  coaptation  of  the  peritoneal  surfaces  was  secured. 

The  omentum  was  dealt  with  by  means  of  Downes'  electro-thermo-cau- 
tery,  and  nearly  the  entire  omentum  was  rem.oved.  On  the  fourth  day  after 
the  herniotomy  a  fourth  recurrent  attack  of  apendicitis  came  on.  I  opened 
the  abdomen  through  the  right  rectus  muscle  and  removed  a  non-adherent 
gangrenous  appendix.  I  then  had  an  opportunity  to  explore  the  internal 
aspect  of  the  seat  of  the  herniotomy.  There  were  no  adhesions  at  the  scar 
nor  of  the  omental  stumps,  but  the  bowels  were  glued  together  pretty  thor- 
oughly, and  distended.  Upon  pushing  the  sigmoid  (which  was  over  on  the 
right  side)  back  to  the  left  and  upward (  gas  began  to  escape  per  anus.  A 
rectal  tube  was  inserted  to  facilitate  the  emission  of  the  gas,  and  with  the 
manipulation  of  the  most  distended  section  of  bowel  it  was  soon  emptied. 
I  broke  down  many  adhesions  and  feared  the  outcome,  but  the  patient  made 
a  perfect  recovery. 

The  agglutination  of  the  bowel  was  no  doubt  due  to  plastic  material 
thrown  out  on  the  surface  of  the  peritoneum  to  repair  the  damage  done  to  it 
by  strangulation  and  by  the  handling  it  received  at  the  operation.  When 
the  exudate  is  sterile  there  is  no  peritonitis  present  but  the  condition  known 
as  traumatic  inflammation  does  exist  and  certainly  predisposes  to  an  infec- 
tive peritonitis.  I  presume  every  surgeon  of  experience  in  the  surgery  of 
the  peritoneum  has  demonstrated  by  operation 'the  fact  that  sometimes  ex- 
tensive peritoneal  adhesions  vanish  by  absorption. 

Primary  intestinal  agglutination  gives  rise  to  distressing  and  even  dan- 
gerous symptoms.  The  vomiting  is  more  persistent  than  that  usually  caused 
by  the  anesthetic,  but  is  less  persistent  than  that  of  peritonitis,  and  bile  is 
rarely  ejected.  The  temperature  is  higher  than  normal,  99'^  F.  to  101°  F., 
but  rarely  higher ;  the  pulse  is  accelerated  but  remains  regular  and  of  good 
volume.  Tenderness  on  pressure  and  tympanitis  are  less  severe  and  exten- 
sive than  in  peritonitis,  the  bowels  functionate  and  the  patient  lacks  the 
facial  expression  and  mental  anxiety  present  in  peritonitis.  Leucocytosis  is 
not  marked,  if  present  .at  all. 

When  the  distended  bowel  presses  upon  the  diaphragm,  dangerous 
respiratory  and  heart  symptoms  may  arise  and  temporary  ileus  occasionally 
occurs  caused  by  the  pressure  of  the  tympanitis.  The  lymph  is  absorbed 
in  from  2  to  4  days, — in  just  about  the  same  time  that  a  traumatic  swelling 
and  eden-ia  of  the  hand  or  foot  subsides.  Indeed  the  traumatic  exudates  sub- 
side sooner  in  the  peritoneal  cavity  than  in  the  hand  or  foot,  unless  the  skin 
is  freely  punctured  to  allow  drainage.  When  recovery  takes  place  the 
tympanitis  gradually  subsides,  the  pain  lessens,  the  temperature  falls  and 
the  patient  feels  more  comfortable. 

So  closely  do  the  symptoms  caused  by  plastic  or  traumatic  exudates  re- 
semble those  of  peritonitis  that  no  one  can  positively  differentiate  the  one 
condition  from  the  other  during  the  first  three  days  after  the  operation.  It 
is  the  prevention  of  the  so-called  "traumatic  peritonitis"  that  should  concern 
the  surgeon.  The  minimum  exposure  and  handling  of  the  peritoneum, 
omentum  and  bowels ;  the  covering  of  raw  surfaces ;  the  exclusion  of  anti- 


174  COMPLICATIONS    IXCIDEXT   TO    THE   RELIEF   OF    HERNIA 

septic  solutions  from  the  peritoneum ;  absolute  control  of  hemorrhage  and 
proper  purgation  of  the  patient  before  operation  are  the  main  prophylactic 
measures. 

AMiile  it  is  generally  admitted  that  free  saline  purgation  is  the  treat- 
ment par  excellence  of  traumatic  (peritonitis)  exudates  interfering  with  the 
alimentary  canal,  still  when  it  is  used  at  the  wrong  time  much  suffering  is 
inflicted  upon  the  patient.  It  is  a  good  plan  to  give  three  or  four  grains  of 
calomel 'three  hours  before  the  operation:  wash  out  the  stomach  on  the  op- 
erating table,  if  it  is  dilated,  and  then  even  before  the  patient  is  fully  awake 
administer  citrate  of  magnesia.  If  purgation  is  not  commenced  im.mediately 
after  the  operation,  it  is  folly  to  attempt  it  during  the  second  and  third  days 
because  the  bowels  are  in  a  splint  and  purgatives  do  not  produce  peristaltic 
action  until  the  muscular  coats  of  the  bowel  are  more  or  less  liberated  by 
the  absorption  of  the  traumatic  exudates  through  the  peritoneum  and  blood 
vessels.  Purgation  during  those  two  days  usually  causes  vomiting  and  adds 
to  the  distress  of  the  patient.  Beginning  at  the  end  of  the  third  day,  small 
doses  of  calomel,  gr.  i-io,  every  20  minutes,  till  gr.  ii  are  taken,  and  then 
citrate  of  magnesia,  two  hours  after  the  last  dose  of  calomel,  is  a  practical 
mode  of  dealing  with  the  bowels  in  this  condition.  This  does  not  exclude 
the  passing  of  a  rectal  tube  or  a  large  self-retaining,  male,  soft  rubber  cathe- 
ter to  carry  off  flatus.  If  it  is  deemed  wise,  and  it  usually  is,  administer 
nutrient  enemata  alternately  with  stimulating  enemata,  and  colonic  flushings 
everv  6  or  8  hours.  (See  Tympanitis.)  Assafetida,  turpentine,  glycerin, 
alum,  etc.,  serve  a  good  purpose,  as  soon  as  the  tympany  begins,  in  pre- 
venting extreme  bloating.  The  aseptic  chemical  inflammations  are  not  in- 
flammations at  all,  only  an  attempt  on  the  part  of  nature  to  repair  the  dam- 
age done  by  the  destructive  power  of  the  drug. 

PERITONITIS  IN  HERNIA. 

Infection  of  the  peritoneum  is  followed  by  peritonitis.  The  germs 
causing  this  are  the  same  as  those  that  infect  wounds  in  other  parts  of  the 
body.  William  H.  Welch  says,  "It  is  apparent  that  while  there  is  no  reason 
to  doubt  that  pyogenic  cocci  are  specific  agents  of  infection,  the  effects  which 
they  produce  depend  upon  a  variety  of  conditions,  such  as  the  source,  the 
number  and  the  virulence  of  the  micrococci,  the  accompanymg  toxic  sub- 
stances, the  part  of  the  body  invaded,  the  readiness  of  absorption,  the  pres- 
ence of  foreign  bodies  and  the  pathological  products,  the  general  state  of  the 
patient  and  the  condition  and  handling  of  wounded  tissues." 

The  peritoneum  is  capable  of  destroying  a  larger  dose  of  infectious 
micro-organisms  than  are  most  of  the  tissues  of  the  body.  Great  as  is  the 
resistant  power  of  the  peritoneum,  the  vital  resistance  of  the  individual  gen- 
erally plays  such  a  marked  role  in  practical  surgery  that  no  surgeon  can 
give  a  guarantee  that  infection  will  not  occur  after  any  operation  for  the 
relief  of  hernia ;  but,  on  the  other  hand,  the  peritoneum  more  often  escapes 
inflammation  than  does  the  wound  itself,  especially  in  inguinal  and  femoral 
hernias. 

Ever}-  patient  should  be  placed  in  the  best  possible  physical  condition 


PLATE  XXVI]  I. 

Kocher's    Operation    for   Inguinal    Hernia — fourth    step. 
(Saunders  Medical  Hand  Atlas.) 


COMPLICATIO^;S    IXCIDEXT   TO   THE   RELIEF   OF    HERXIA  \jj 

before  the  operation  is  done.  Inasmuch  as  the  individual  is  more  prone  to 
peritonitis  after  operation  when  suffering  from  any  chronic  disease  of  the 
heart,  liver  or  kidneys,  and  inasmuch  as  he  is  also  more  likely  to  have  a  post- 
operative pneumonia,  the  surgeon  should  always  examine  into  the  condition 
of  the  internal  organs  of  the  patient  before  any  operation  is  done.  In  spite 
of  all  care,  micro-organisms  enter  the  wound  every  time  the  peritoneum  is 
opened. 

All  consideration  should  be  given  to  fa)  the  condition  of  the  patient, 
(b)  complete  sterilization,  and  (c)  the  technic  employed.  In.  connection 
wuth  a  hernia,  the  greatest  factor  in  the  causation  of  peritonitis  is  strangula- 
tion of  a  loop  of  bowel  within  the  sac  or,  more  rarely,  intra-abdominal 
necrosis. 

Symptoms. — The  symptoms  of  post-operative  peritonitis  are  both  local 
and  general,  and  they  vary  in  degree  according  to  the  severity  of  the  infec- 
tion. The  onset  may  be  insidious  or  the  condition  may  be  ushered  in  with 
symptoms  of  shock.  Kelly  reports  two  deaths  from  peritonitis.  In  one  case 
the  symptoms  were  so  severe  that  the  case  was  mistaken  for  one  of  sec- 
ondary hemorrhage  and  shock,  when  in  reality  it  was  one  of  streptococcus 
infection.  I  have  seen  the  same  thing  occur  with  extension  of  the  perito- 
nitis after  other  abdominal  operations,  but  I  have  never  seen  a  case  of  peri- 
tonitis following  an  operation  for  the  relief  of  hernia  when  strangulation 
was  not  present. 

Pain. — The  first  symptom  to  manifest  itself  is  pain,  which  may  be  re- 
ferred by  the  patient  to  the  site  of  the  operation.  If  the  affection  is  fulmi- 
nating in  character,  the  pain  at  first  generally  is  something  like  that  exist- 
ing in  the  early  stages  of  a  severe  appendicitis.  The  pain  usuallv  is  remit- 
tent in  character.  There  are  periods  of  calm  and  periods  of  unrest,  accord- 
ing to  the  direction  taken  by  the  inflammation  and  the  structures  involved. 
It  is  not  uncommon  to  have  the  pain  disappear  from  its  original  seat  by  the 
time  the  peritonitis  has  become  general. 

When  the  patient  is  at  the  point  of  death  the  pain  sometimes  ceases. 
The  pain  met  with  in  strangulated  femoral  hernia,  or  a  hernia  of  the  Littre 
variety  where  only  a  part  of  the  lumen  of  the  bowel  is  shut  ofif,  is  verv  de- 
ceptive. Death  of  the  bowel  takes  place  so  rapidly  that  the  patient  com- 
plains of  very  little  or  no  pain.  W^hen  the  peritonitis  extends  to  the  neigh- 
boring tissues,  then  there  appears  the  characteristic  pain  of  peritonitis. 

The  pain  of  peritonitis  followmg  an  operation  must  not  be  mistaken  for 
pain  in  the  abdomen  caused  by  other  conditions,  such  as  the  referred  pain 
of  pleurisy  or  pneumonia,  angina  pectoris  and  aneurism,  or  the  radiating 
pains  of  locomotor  ataxia,  and  of  many  other  conditions. 

Tenderness. — Associated  with  the  pain  is  tenderness.  This  is  usually 
local,  but  becomes  general  when  the  inflammation  extends.  The  tenderness 
is  greatest  at  the  point  where  the  inflammation  is  most  active.  Light  strok- 
ing of  the  skin  will  sometimes  cause  great  inconvenience.  The  tenderness 
may  be  superficial  or  deep. 

Muscular  Rigidity. — Associated  with  this  tenderness  is  muscular  rig- 
idity.   AVhen  the  pain  and  tenderness  disappear,  the  muscles  relax,  and  this. 


178  COMPLICATIOXS    IXCIDENT   TO   IHE   RELIEF   OF   HERNIA 

in  many  instances,  may  be  taken  as  a  sign  of  approaciiing  dissolution.  All 
the  abdominal  reflexes  are  increased  during  the  spread  of  the  disease. 

V^oinifing. — A'omiting  is  one  of  the  early  signs  of  peritonitis,  but  us- 
ually it  does  not  come  on  until  about  three  days  after  the  operation.  Vom- 
iting resulting  from  the  administration  of  the  anesthetic  usually  passes  off  at 
about  the  time  that  the  vomiting  which  is  associated  with  peritonitis  makes 
its  appearance.  If  the  operation  is  done  for  ihe  relief  of  an  umoilical  or 
epigastric  hernia,  or  any  hernia  in  the  upper  abdomen,  and  peritonitis  fol- 
lows, the  vomiting  comes  on  very  early,  on  account  of  the  close  proximity  of 
the  inflammation  to  the  stomach.  The  vomitus  after  a  time  becomes  green  in 
color,  then  dark,  and  finally  it  becomes  fecal  in  character. 

Pulse. — The  rapidity  and  the  high  tension  of  the  pulse  are  very  char- 
acteristic of  peritonitis,  so  much  so  that  the  older  surgeons  still  refer  to  the 
hard  and  wiry  pulse  of  peritonitis.  The  pulse  rate  varies  from  no  to  150. 
The  frequency  of  the  pulse  lessens  as  soon  as  the  spread  of  the  inflammation 
is  checked.  Its  frequency  increases  as  long  as  the  peritonitis  is  active. 
Then  acceleration  of  the  pulse  and  the  persistency  of  this  acceleration  are 
more  characteristic  of  peritonitis  than  is  any  other  single  symptom  met  with 
in  this  disease.  The  pulse  and  respiration  are  increased  in  frequency  and 
the  temperature  rises,  maintaining  a'  physiologic  ratio  while  the  inflammation 
is  spreading.  As  soon  as  the  inflammation  becomes  limited  or  general  the 
temperature  and  respiration  may  vary  in  proportion  to  the  pulse  rate. 

Temperature. — The  temperature  increases  for  about  three  or  four  days 
after  the  operation.  In  cases  of  so-called  traumatic  peritonitis,  in  vvhich  an 
infection  is  grafted  on  the  peritonitis,  the  temperature  of  the  one  condition 
merges  into  that  of  the  other  .  There  may  be  gangrene  of  the  bowel  and 
extensive  peritonitis  with  a  subnormal  temperature.  The  temperature  of 
peritonitis  is  rather  deceptive  and  considered  alone  cannot  be  relied  on  as  a 
pathognomonic  symptom. 

Shock. — Shock  is  always  present  to  a  greater  or  less  degree  in  perito- 
nitis. In  cases  where  the  onset  is  sudden  and  severe,  shock  may  be  very 
marked. 

Increased  Peristalsis. — Increased  peristaltic  action  is  present  early  in 
the  disease,  but  is  soon  put  in  abeyance,  so  that  the  bowels  become  perfectly 
motionless.  At  the  margins  of  the  inflammatory  area  peristalsis  is  most  ac- 
tive. If  the  inflammation  invades  the  intestinal  tract  from  below  upward, 
retroperistalsis  is  established,  which  produces  nausea  and  vomiting,  even 
when  the  inflammation  has  not  extended  to  the  stomach. 

By  listening  over  the  abdomen  with  a  stethoscope  one  can  usually  locate 
the  most  active  area  of  the  inflammation  by  the  friction  sound  that  is  heard. 
At  the  margins  of  the  inflammatory  area  there  is  always  more  or  less  peris- 
talsis, and  it  is  here  that  one  can  hear  the  various  noises  that  are  produced 
by  the  intestinal  contents  working  to  and  fro  in  the  lumen  of  the  bowel. 

Tympany. — Tympany  is  present  v.'ith  inflammation  of  the  peritoneum. 
The  distention  of  the  bowels  becomes  greater  until  eventually  the  abdomen 
is  like  a  drum,  and  a  resonant  percussion  note  is  elicited.  .This  distention  is 
present  even  when  there  is  no  inflammation. 


COMPLICATIONS    INCIDENT   TO'  THE   RELIEF   OF    HERNIA  I79 

The  facial  expression  of  one  suffering  from  post-operative  peritonitis  is 
that  of  great  anxiety.  The  mind  remains  clear  until  exhaustion  occurs,  or 
when  the  temperature  becomes  high  the  patient  may  be  found  to  be  delirious 
between  the  intervals  of  sleep.  When  the  final  collapse  comes  and  the  patient 
is  dying,  he  usually  is  unconscious. 

Blood.— An  aid  to  the  early  diagnosis  of  post-operative  peritonitis  is  an 
examination  of  the  blood.  The  leucocytes  are  increased  in  number,  espe- 
cially the  polymorphonuclear  variety.  The  coagulability  of  the  blood  is  also 
increased.  The  presence  of  leucocytosis  is  not  to  be  relied  on  too  firmh', 
however,  as  a  diagnostic  aid. 

Treatment. — The  treatment  of  post-operative  peritonitis  is  both  medi- 
cal and  surgical.  The  only  medical  treatment  that  is  of  any  benefit  at  all  is 
that  which  drains  the  alimentary  canal  by  means  of  cathartics,  carrying 
away  the  germs  and  their  products,  or  the  administration  of  opium,  which 
lessens  the  pain,  prevents  peristalsis,  and  also,  to  a  considerable  degree,  ttle 
spreading  of  the  inflammation.  During  the  early  development  of  abdominal 
surgery  Lawson  Tait  instituted  and  practised  free  catharsis,  beginning  it  im.- 
mediately  after  the  operation,  as  a  prophylactic  against  post-operative  com- 
plications, such  as  peritonitis.  Cathartics  are  of  no  avail,  however,  once  the 
inflammation  is  established.  When  peristalsis  cannot  take  place  the  admin- 
istration of  cathartics  may  do  harm. 

Opiates  are  indicated  for  the  relief  of  sufit'ering  and  also  to  prevent  the 
spasmodic  contractions  of  the  alimentary  canal.  If  it  is  decided  to  give 
opiates  in  the  treatment  of  peritonitis,  they  ought  to  be  pushed  to  the  extern; 
almost  of  poisoning  the  patient  so  that  no  tenderness  is  felt. 

The  medical  treatment  is  also  local  in  the  form  of  turpentine  stupes  and 
other  methods  of  applying  heat  and  moisture,  these  being  verv  grateful  to 
the  patient  by  relieving  him  of  his  suffering.  The  ice  pack  is  indicated  earlv 
in  the  disease  and  then  only  for  a  very  limited  time. 

The  large  bowel  should  be  kept  emptv  by  means  of  colonic  flushings. 
Much  relief  is  also  afforded  by  stomach  lavage,  and  it  is  a  good  routine 
practice  to  wash  out  the  stomach  regularly.  Patients  who  have  had  their 
stomach  washed  out  will  frequently  ask  to  have  the  procedure  repeated  be- 
cause of  the  relief  it  gives  them.  The  medical  treatment  usually  is  just  as 
successful  as  is  the  surgical. 

In  post-operative  peritonitis  the  infection  that  causes  the  peritonitis  has 
been  carried  into  the  abdomen  either  by  the  operator  or  his  assistants,  or  bv 
the  materials  that  were  used  during  the  operation.  The  only  surgical  treat- 
ment in  this  condition  is  to  open  the  abdomen  and  drain.  When  the  patient 
has  a  temperature  and  complains  of  local  pain  in  the  wound  and  tenderness 
in  the  abdomen,  with  muscular  rigidity,  a  rapid  pulse,  and  a  flushed  face ; 
on  about  the  third  day  after  the  operation,  the  wound  should  be  explored  by 
removing  a  stitch  or  two  and  inserting  the  gloved  finger  into  its  very  depths. 
The  peritoneum  is  thus  given  an  opportunity  to  take  care  of  the  germs  that 
are  invading  it,  provided  they  are  directed  into  another  channel,  and  that  is. 
outward  by  drainage. 

Of  course,  this  procedure  will  have  a  tendency  to  nullify  the  radical 


l80  COMPLICATIONS    INCIDENT   TO   THE   RELIEF   OF    HERNIA 

Operation  for  the  cure  of  hernia,  but  infection  is  one  of  the  causes  of  recur- 
rence of  the  hernia  and  when  it  is  present  it  is  well  to  recognize  the  fact  that 
drainage  is  imperative,  even  at  the  risk  of  iiaving  a  recurrence  of  the  hernia. 

The  most  dangerous  form  of  peritonitis  associated  wath  hernia  is  that 
which  affects  the  Iood  of  bow^el  that  was  strangulated  after  it  is  returned 
within  the  abdomen  and  the  rush  of  blood  into  it  is  so  great  as  to  cause  a 
local  peritonitis  which,  according  to  the  nature  of  the  germs  causing  it,  may 
or  may  not  become  general.  In  the  case  of  a  peritonitis  that  comes  on  after 
an  operation  for  a  hernia  that  was  not  strangulated,  I  cannot  see  very  much 
to  justify  opening  the  abdomen,  washing  out  the  peritoneal  cavity,  breaking 
down  adhesions,  thus  spreading  the  inflammation  and  hurrying  the  death 
of  the  patient,  unless  it  is  done  before  the  expiration  of  the  first  three  days 
of  the  disease,  because  after  that  any  interference  is  useless. 

I  recollect  operating  on  a  young  woman  in  the  Winnipeg  General  Hos- 
pital, in  1889,  removing  a  dermoid  cyst.  The  operation  was  a  simple  and 
an  easy  one,  and  I  had  no  anxiety  whatever  about  the  case,  but  immediately 
following  the  operation  severe  gastro-intestinal  disturbances  manifested 
themselves.  Within  forty-eight  hours  the  temperature  rose  to  103''  F.,  the 
pulse  was  120,  the  face  was  flushed,  there  was  vomnting  and  distention,  and 
all  the  characteristic  sym.ptoms  of  peritonitis  rapidly  coming  on.  I  inquired 
about  the  materials  that  were  used  during  the  operation,  and  learned  that 
two  extra  sponges  had  been  used,  the  asepticity  of  which  could  not  be 
vouched  for.  At  two  o'clock  in  the  morning  I  opened  the  abdomen  again, 
and  found  the  intestines  congested,  wuth  flakes  of  lymph  floating  in  the  fluid 
present  inside  of  the  abdomen.  The  small  intestine  imimediately  above  the 
brim  of  the  pelvis  was  involved  quite  extensively.  The  perit-oneum  was  not 
yet  denuded.  I  washed  out  the  abdominal  cavity  with  a  considerable  quan- 
tity of  plain  sterile  water,  and  finished  the  flushing  with  a  couple  of  pitchers 
full  of  normal  salt  solution.  I  left  the  abdomen  full  of  the  salt  solution  and 
closed  the  wound  with  through-and-through  sutures.  Six  hours  afterward 
the  lady  was  free  from  pain  and  the  abdomen  was  flat.  All  the  fluid  had 
been  absorbed  and  the  temperature  had  fallen  to  100°  F.  Immediately  after 
the  washing  out  of  the  abdomen  the  temperature  rose  to  105'^  F.,  but  fell 
subsequently,  as  stated.  The  patient  made  a  perfect  recovery,  the  reason 
being,  of  course,  that  the  peritoneum  was  not  destroyed  by  the  inflammation. 

The  simple  irrigation  of  an  infected  peritoneal  cavity  is  worthless.  If 
anything  at  all  is  to  be  done  in  the  nature  of  cleansing  the  peritoneal  cavity 
it  must  be  done  by  flushing,  pouring  the  fluid  from  a  pitcher  or  carrying  it  to 
the  furthest  parts  of  the  abdominal  cavity  through  a  tube  an  inch  in  diame- 
ter, and  to  be  of  benefit  this  must  be  done  early  in  the  course  of  the  disease. 

The  practice  of  evisceration  and  flushing  for  the  treatment  of  peritonitis 
is  accompanied  by  a  great  deal  of  shock.  It  lessens  the  vital  powers  of  the 
patient  very  much,  and  it  should  not  be  done  in  cases  of  post-operative  peri- 
tonitis. 

If  the  abdomen  is  opened  and  accumulations  of  fluid  or  pus  are  found 
in  different  parts  of  the  cavity,  the  patient  should  receive  the  benefits  of 
drainage  of  those  parts,  Douglas'  pouch,  Morrison's  pouch,  the  kidney  re- 


PLATE   XXIX. 
Halsted's   Operation   for   Ini^uinal    Hernia. 


COMPLICATIOXS    IXCIDEXT   TO   THE    RELIEF   OF    HERNIA  183 

gion,  or  wherever  the  accumulation  happens  to  be.  A  drain  should  be  in- 
serted through  a  separate  incision  in  the  abdominal  wall,  taking  the  most 
direct  route. 

Strangulation  of  the  bowel  following  a  localized  peritonitis,  post-opera- 
tive or  otherwise,  should  be  treated  by  laparotomy,  if  the  patient's  condi- 
tion will  permit  of  it.  If  not,  the  bowel  may  be  drained,  a  simple  enterostomy 
being  performed  on  tbe  most  distended  portion.  This  can  be  done  under 
local  anesthesia.  A  self-retaining  catheter  is  pushed  through  an  opening  in 
the  bowel  and  circular  stitches  are  applied.  If  there  is  any  complication  in 
which  the  surgeon  is  justified  in  doing  anything,  it  is  peritonitis,  and  every- 
thing that  promises  the  slightest  opportunity  of  improvement  to  the  patient 
should  be  emplo3'ed. 

Immunizing  injections  for  the  prevention  of  peritonitis  liave  been  prac" 
tised.  This  is  a  step  in  the  right  direction.  When  resection  of  bowel  is 
demanded  in  hernia,  fatal  peritonitis  occasionally  developes  in  spite  of  all 
precautions  and  the  degree  of  the  infection  overcomes  the  resistance  of  the 
peritoneum.  Since  we  cannot  be  certain  of  asepticity  in  intestinal  anasto- 
moses, it  would  appear  that  should  something  be  found  that  would,  when  in- 
jected into  the  circulation,  aid  the  peritoneum  in  overcoming  the  bacteria 
invading  it  a  very  valuable  advance  would  be  made. 

It  has  been  observed  (Salieri)  that  normal  saline  solution  injected  in 
small  quantities  increases  the  normal  resistance  of  the  peritoneum  from 
seven  to  sixteen  fold  against  bacillus  coli  infection.  Mikulicz-Radecki  (West 
London  Med.  Jour.,  July  i,  1904)  first  demonstrated  that  hypodermic  injec- 
tions of  0.5  per  cent,  neutralized  nucleinic  acid  produce  artificial  hyperleu- 
cocytosis  of  bactericidal  value,  and  increase  the  normal  resistance  of  the 
peritoneum  from  sixteen  to  twenty  times.  When  repeated  injections  were 
made  intra-peritoneally.  the  increase  was  as  high  as  forty  times  the  natural 
resistance.  Robson  {International  Medical  Annual,  1906,  p.  361 ),  as  a  pre- 
paratory measure  for  operations  on  the  gastro-intestinal  tract,  savs,  "As  a 
rule  50  c.  c.  of  a  2  per  cent,  solution  was  used.  The  adult  man  received 
about  I  gram  of  nucleinic  acid  to  75  kilos  of  the  body  weight.  Fiftv -eight 
cases  were  treated  in  this  way.  In  fifty-five  the  operations  were  abdominal. 
In  four  cases  the  operations  were  postponed  so  that  they  did  not  take  place 
until  more  than  thirty- four  hours  after  the  injection  was  given.  As  in  ani- 
mals there  was  constantly  observed  in  man  a  hyperleucocytosis  in  the  blood, 
mostly  preceded  during  the  first  hour  or  so  by  h}-poleucocytosis.  The  opera- 
tions were  mostly  performed  in  from  thirteen  to  nineteen  hours  after  the  in- 
jection. The  optimum  for  nucleinic  acid  injection  is  reached  in  animals  in 
seven  hours,  but  it  seems  to  occur  in  man  considerably  later.  Twelve  hours 
is  the  time  fixed  by  experience,  which  enables  the  surgeon  to  operate  on  the 
rising  tide  of  leucocytosis." 

On  page  2^2,  he  says,  "The  general  impression  gained  from  this  method 
is  that  while  it  gives  no  absolutelv  certain  immunization,  it  increases  the 
natural  immunity  and  that  the  cases  treated  by  it  have  given  more  favorable 
results  both  as  to  ultimate  recovery  and  smooth  convalescence,  than  cases 
where  the  operations  were  performed  without  this  preparation." 


184  COMPLICATIONS   INCIDENT   TO    THE   RELIEF   OF    HERNIA 

Arndt  {Ceiitr.  f.  Gyu.,  March  5.  1904 j,  after  three  years'  experience, 
recommends  eserine  sahcylate,  0,001  gram  hypodermically,  for  post-opera- 
tive intestinal  paralysis.  He  has  not  used  more  than  2  mg.  in  24  hours.  If 
the  drug  is  not  effective  microbic  infection  is  most  likely  present.  It  begins 
to  cause  peristalsis  in  from  15  to  30  minutes,  as  is  evidenced  by  borborygmi 
and,  finally,  in  about  an  hour  by  the  passage  of  flatus.  Eserine  may  be  used 
in  doses  of  1-40  of  a  grain.  It  is  a  spinal  depresso-motor  and  counteracts  the 
inhibitorv  reflexes  of  the  splanchnics  present  in  intestinal  paralysis  follow- 
ing operations.  Manipulations  of  tlie  intestines  necessarily  carried  out  at 
operations  stimulate  the  splanchnic  nerves  to  produce  reflex  inhibition  along 
the  whole  intestinal  canal  and  paralysis  is  the  result. 

PNEUMOCOCCUS  PERITONITIS. 

This  may  occur  after  operation  involving  the  peritoneum.  Mathews 
{Ann.  Surg.,  Nov.,  1904)  reports  live  cases.  Jensen  records  106  cases  of 
pneumococcus  peritonitis.  Several  observers  have  seen  about  half  a  dozen 
cases.  It  may  be  much  more  frequent  than  is  supposed.  The  only  way  to 
determine  the  special  cause  of  peritonitis  is  by  means  of  a  bacteriological  ex- 
amination of  the  inflammation  products.  The  pneumococcus  infects  other 
structures  of  the  body  more  frequently  than  it  does  the  peritoneum.  In  per- 
sons dying  of  pneumonia  (pneumococcus)  Netter,  Flexner,  and  others,  have 
regularlv  demonstrated  this  germ  in  cover-slip  preparations  from  the  perito- 
neum and  no  evidence  of  peritonitis.  In  peritonitis  the  pneumococcus  was 
found  in  7  per  cent.  (2  cases  in  140,  Netter).  It  is  more  frequent  in  chil- 
dren (2  to  i).     Mixed  infection  is  rare. 

The  pathologic  appearance  is  characterized,  as  in  empyema,  by  an  ex- 
tremely fibrinous  and  odorless  greenish  yellow  exudate.  Large  loose  masses 
of  fibrin  are  often  found  floating  in  a  liquid  or  semi-solid  exudate.  When 
the  inflammation  is  general  the  thick,  fibrinous  lymph  covers  the  entire  sur- 
face of  the  peritoneum.  The  usual  tendency  of  the  process  is  to  terminate  in 
localized  abscesses  with  very  thick  walls.  Some  of  them  have  been  known 
to  rupture  spontaneously  even  through  the  skin.  Robson  declares  that  80  per 
cent,  of  the  patients  ma}^  be  expected  to  recover  when  the  disease  has  be- 
come localized.     If  the  other  form,  (diffuse)  is  present  there  is  no  hope. 

The  majority  of  cases  of  pneumococcus  peritonitis  have  been  primary. 
As  might  be  expected  pneumonia  has  developed  secondarily.  Although  the 
diagnosis  has  not  been  commonly  made  until  the  termination  of  the  disease, 
still  its  symptoms  and  course  are  quite  different  from  other  forms  of  peri- 
tonitis. 

Syiiipfor/is.  Much  prominence  is  given  by  observers  to  the  sudden  on- 
set, early  high  fever,  with  vomiting,  pain,  tenderness  on  pressure  and  dis- 
tention. The  muscular  rigidity,  pain,  and  tympany  are  not  comparatively 
marked.  In  three  or  four  days  the  vomiting  usually  stops,  the  temperature 
falls  and  diarrhea,  if  not  present  from  the  start,  as  it  sometimes  is,  comes  on 
with  the  amelioration  of  the  above  mentioned  symptoms  and  signs. 

Marked  evidence  of  intra-abdominal  exudates  resembling  a  tense  cyst 
or  cysts  is  next  found.     The  high  temperature  returns,  with  morning  and 


PLATE  XXX. 
Halsted's  Operation  for  Ingumai  Hernia. 


COMPLICATIOXS    IXCIDEXT   TO   THE   RELIEF   OF    HERXIA  187 

evening  remissions.  The  inflammation  becomes  localized.  The  surgeon 
should  not  hesitate  to  at  once  drain  the  abscess  or  abscesses,  as  the  case  may 
be.  There  are  many  avenues  of  infection.  In  one  case  the  infection  en- 
tered through  the  wound,  following  a  hernia  operation  (Jensen).  Through 
the  intestinal  tract  secondary  to  intestinal  ulceration  (Flexner)  or  ulcer  of 
the  stomach  is  another  method  of  invasion ;  or  through  the  blood,  or  through 
the  diaphragm  by  extension  from  the  thorax. 

POST-OPERATIVE  PYREXIA. 

Post-operative  pyrexia  often  occurs  when  bacteria  are  not  an  etiologic 
factor.  There  are  two  distinct  periods  after  operations  when  there  may  be 
an  elevation  of  temperature.  One  period  is  between  the  first  and  third  days 
and  the  other  between  the  eighth  and  tenth.  During  the  first  period  there 
occurs  what  T  call  the  primary  fc7:cr.  Von  Bergmann  and  others  designate 
this  as  fermentation  fever.  It  comes  on  soon  after  the  operation  and  termi- 
nates spontaneously  within  two  or  three  days.  I  have  seen  an  elevation  in 
temperature  occur  during  the  operation  on  cases  of  extensive  hernia  with 
incarceration,  or  where  there  was  much  manipulation  of  the  bowel.  The 
same  thing  occurs  when  extensive  adhesions  must  be  broken  down.  It  is 
certain  that  in  cases  such  as  these  fermentation  could  not  have  taken  place. 
The  fever  must,  therefore,  be  due  to  the  absorption  of  fibrin  and  other  pro- 
teid  substances. 

An  examination  of  the  blood  does  not,  as  a  rule,  reveal  any  marked  leu- 
cocytosis,  nor  are  bacteria  found,  either  microscopically  or  in  culture. 

SECONDARY  FEVER. 

Secondary  fever  comes  on  usuallv  about  the  eighth  to  the  tenth  day 
after  operation,  especially  in  cases  in  which  the  omentum  was  removed  ex- 
tensively, or  adhesions  broken  down,  or  vessels  of  considerable  size  ligated. 
Apparently  for  no  reason  w^hatever  the  patient  becomes  feverish,  his  temper- 
ature rises  to  99'^  or  lOQ-'  F.,  or  even  up  to  103".  Within  twenty-four  to 
forty-eight  hours  the  fever  subsides  spontaneously. 

This  elevation  of  temperature  is  usually  ascribed  to  an  indiscretion  in 
the  diet,  to  exposure,  to  too  much  mental  excitement,  etc.,  but  secondary 
fever  occurs  in  patients  v/hen  no  cause  whatever  is  discoverable. 

An  examination  of  the  blood,  fails  to  reveal  any  bacteria,  but  sometimes 
a  marked  leucocytosis  is  present ;  so  that  some  other  explanation  of  the  fever 
must  be  sought  for.  I  am  of  tne  opinion  that  the  fever  is  due  to  the  absorp- 
tion of  thrombi  and  emboli  which  are  undergoing  fatty  degeneration.  The 
organization  of  a  clot  is  often  accompanied  by  an  elevation  of  the  tempera- 
ture. This  phenomenon  ip  not  always  accompanied  by  chills  or  by  other 
symptoms  of  inflammation. 

SEPTIC  INTOXICATION. 

Patients  suffering  from  strangulation  of  the  bowel,  local  peritonitis,  or 
abscess  may  have  an  increased  temperature  during  the  operation.  This  tem- 
perature is  due  to  the  absorption  of  pus  either  by  the  peritoneum  or  by  the 


>. 


l88  COMPLICATIONS   INCIDENT   TO   THE   RELIEF   OF    HERNIA 

wounded  tissues.  This  septic  intoxication  is  very  noticeable  in  gynecologic 
surgery. 

Although  auto-intoxication  may  be  said  to  be  a  variety  of  septic  intoxi- 
cation, there  is  a  difference  between  the  two,  particularly  in  cases  of  stran- 
gulated hernia,  although  these  terms  are  used  interchangeably.  The  patient 
may  die  from  the  absorption  of  toxins  in  the  alimentary  canal,  even  though 
there  may  have  been  no  peritonitis  following  the  operation.  Particular 
stress  was  laid  on  this  by  the  late  Greig  Smith. 

Auto-intoxication  from  this  cause  may  occur  either  immediately  fol- 
lowing the  operation  done  to  relieve  the  strangulated  bowel,  or  it  may  not  be 
manifested  until  the  end  of  a  week  or  ten  days,  when  the  bowel  again  be- 
comes active. 

Sapremia  may  follow  a  hernia  operation,  and  the  germs  causing  it  may 
have  been  implanted  in  the  wound  by  the  operator.  This  condition  is  also 
known  as  septic  or  putrid  blood  poisoning.  It  is  invariably  caused  by 
the  entrance  into  the  blood  of  the  toxins  produced  by  putrefactive  bac- 
teria. There  are  no  germs  to  be  found  in  the  blood.  Leucocytosis,  if  present 
at  all,  is  slight.  The  patient  usually  recovers  within  a  day.  There  are  cases 
on  record,  however,  where  the  poisoning  is  so  violent  that  the  patient  suc- 
cumbs. 

SEPTICEMIA. 

Septicemia  has  also  been  known  to  occur  after  hernia  operations.  It  is 
caused  by  the  absorption  into  the  blood  of  pathogenic  bacteria  and  their 
products.  The  condition  is  manifested  by  chills,  fever,  sweating,  rapid  pulse, 
increased  frequency  of  respiration,  flushing  of  the  face,  etc.  Except  when 
the  causative  germ  is  extremely  virulent,  when  death  occurs  within  twenty- 
four  to  forty-eight  hours,  there  is  always  a  leucocytosis.  Although  the 
germs  are  always  contained  in  the  circulating  blood,  it  is  not  always  possible 
to  find  them,  except  when  cultures  are  made. 

The  most  severe  forms  of  septicemia  are  those  caused  by  the  strepto- 
cocci, because  they  continue  to  elaborate  their  toxins  in  spite  of  the  bacteri- 
cidal action  of  the  blood  serum. 

Septicemia  may  :dso  be  caused  by  other  bacteria  such  as  the  staphy- 
lococcus pyogenes  aureus  and  the  bacillus  acrogenes  capsulatus  (Welch), 
which  is  the  specific  cause  of  a  particularly  virulent  form  of  septicemia  al- 
most invariably  causing  death  of  the  patient.  The  pneumococcus  and  the 
members   of  the  colon   group  of  bacilli   are  not   so   fatal  in  their   results. 

The  treatment  of  this  condition  consists  in  thorough  and  speedy  elimi- 
nation by  kidneys,  bowels  and  skin,  and  supporting  the  strength  of  the  pa- 
tient with  stimulants.  The  antistreptococcus  serum  so  far  has  proven  a 
failure  for  obvious  reasons. 

PYEMIA. 

Pyemia  is  a  form  of  septicemia  with  the  accumulation  of  necrotic  ma- 
terial in  different  parts  of  the  body  in  sufficient  quantity  to  cause  the  forma- 
tion of  local  abscesses. 


PLATE  XXXI. 
Halsted's  Operation  for  Inguinal  Hernia. 


COMPLICATIONS    INCIDENT   TO   THE   RELIEF   OF    HERNIA  I9I 

PLEURISY  AND  BRONCHITIS. 

Pleurisy  and  bronchitis  are  two  conditions  that  have  been  known  to  fol- 
low operations  for  the  cure  of  hernia,  but  not  any  more  frequently  than  after 
operations  done  for  the  relief  of  other  conditions. 

PNEUMONIA. 

A  number  of  operators  have  pointed  out  that  pneumonia  occurs  not  in- 
frequently after  operations  done  for  the  relief  of  hernia,  especially  when 
ether  was  the  anesthetic  used.  Kelly  met  with  only  one  case  of  pneumonia 
following  chloroform  anesthesia,  but  he  has  seen  six  cases  following  the  use 
of  ether.  Bull  reports  five  cases  of  pneumonia  with  one  death.  Other  op- 
erators have  informed  me  that  they  have  met  with  post-operative  pneumonia 
in  about   the    same   proportion   of   cases. 

In  looking  over  my  operative  work  of  all  kinds  done  since  1887,  I  find 
that  I  have  seen  only  one  case  of  post-operative  pneum.onia.  This  occurred 
in  a  man,  65  years  of  age,  who  had  a  double  hernia,  one  side  being  strangu- 
lated and  the  other  incarcerated.  He  had  also  been  the  subject  of  a  very  se- 
vere bronchitis  for  a  number  of  years.  I  have  always  made  it  a  rule  to  give 
my  patients  the  best  of  care  before,  during  and  after  the  operation,  and  to 
this,  I  think,  may  be  ascribed  the  infrequency  of  the  occurrence  of  post-oper- 
ative pneumonia  in  my  work. 

Post-operative  pneumonia  is  due  to  (a)  exposure,  which  lowers  the 
vitality  of  the  patient;  (b)  the  irritating  effects  of  the  anesthetic,  particu- 
larly when  ether  is  used;  (c)  the  inspiration  of  mucus,  blood  or  other  fluids, 
producing  what  is  known  as  an  inspiration  pneumonia,  and  (d)  septic  em- 
bolus, which  produces  a  form  of  pyemic  pneumonia. 

Many  other  septic  complications  have  been  met  with  in  connection  with 
the  surgery  of  hernia,  such  as  phlebitis  of  the  leg,  abscess  of  the  parotid 
gland,  dysentery,  acute  otitis  media,  erysipelas,  infection  of  a  hydronephro- 
sis, etc. 

NEPHRITIS. 

Nephritis  is  one  of  the  post-operative  complications  which  often  proves 
fatal.  Before  operating  on  a  hernia  the  condition  of  the  kidneys  should  be 
ascertained.  A  very  excellent  article  on  this  subject  by  Flexner  appeared  in 
the  Journal  of  Experimental  Medicine,  Volume  T,  No.  3,  1896,  in  which  was 
presented  a  statistical  and  experimental  study  of  terminal  infections.  In 
793  autopsies  Flexner  found  that  255  subjects  had  had  chronic  heart  or  kid- 
ney diseases,  or  both.  Of  this  number,  213  were  due  to  bacteria,  the  infec- 
tion being  either  local  or  general. 

In  anticipation  of  a  disturbance  of  the  kidney  function  after  operation, 
we  frequently  resort  to  hypodermoclysis  of  normal  salt  solution  during  the 
operation.  If  before  the  operation  the  amount  of  urine  secreted  is  less  than 
normal,  and  if  the  urine  contains  albumin  and  a  few  hyaline  casts,  it  is  ad- 
visable to  extend  the  time  of  preparation,  postposing  the  operation  until 
such  time  as  the  urine  is  again  normal.  Of  course  in  cases  of  strangulated 
hernia  this  cannot  be  done.  The  operation  must  be  performed  irrespective  of 
the  condition  of  the  kidneys. 


ig2  COMPLICATIONS    INCIDENT    TO   THE   RELIEF   OF   HERNIA 

After  the  operation  has  been  performed,  the  function  of  the  kidneys 
must  be  watched  carefuHy.  If  suppression  of  urine  takes  place,  and  is  per- 
sistent, it  is  advisable  to  do  a  nephrotomy  on  one  kidney.  Then  the  anuria 
cannot  continue.  I  have  seen  a  patient  live  without  any  kidneys  at  all  for  ten 
days.  The  woman  had  only  one  kidney  and  it  became  necessary  to  remove 
that.  I  am  convinced  that  some  patients  who  die  with  symptoms  simulat- 
ing those  of  uremia  are  leally  suffering  from  an  infection,  the  uremic 
s\-mptnms  being  due  to  the  inabijity  of  the  kidneys  to  eliminate  the  infec- 
tion. 

TJUmAUY  FISTULA. 

A  urinary  fistula  is  the  direct  result  of  an  injury  to  the  bladder.  Not  a 
few  cases  are  recorded  in  which  the  bladder  was  injured  during  an  opera- 
tion for  the  relief  of  an  inguinal,  femoral  or  a  ventral  suprapubic  hernia. 
These  fistulas  should  be  repaired  immediately.  There  is  no  justification  for 
delaying  the  repair  of  a  fistula.  Any  operator  of  ordinary  skill  and  ability 
can  close  one.  I  have  had  two  cases  referred  to  me  for  operation,  and  I  saw 
one  case  in  consultation  where  the  urinary  fistula  caused  extravasation  of 
the  urine  with  peritonitis  and  death. 

FECAL  FISTULA. 

The  occurrence  of  a  fecal  fistula  after  a  hernia  operation  is  sometimes 
unavoidable,  especially  when  the  hernia  has  been  strangulated.  When  a  loop 
of  bowel  is  strangulated  to  the  extent  that  its  viability  is  in  doubt,  the  rule  is 
to  return  the  bowel  to  the  abdominal  cavity,  because  it  is  more  likely  to  live 
there  than  inside  of  the  sac.  It  is  surprising  how  many  of  these  doubtful  loops 
of  bowel  cause  no  symptoms  whatever  after  they  are  replaced  in  the  abdomi- 
nal cavity.  But  when  such  a  loop  of  bowel  is  returned  to  the  abdominal  cavity, 
the  wound  should  not  be  closed,  and  in  these  cases  it  is  bette~r  to  leave  a  con- 
siderable portion  of  the  sac  protruding  beyond  the  skin.  This  forms  a  nice 
funnel  for  packing  the  wound  with  gauze,  and  it  also  serves  as  an  exit  for 
fluids  and  other  material.  If  the  loop  or  a  portion  of  it  dies,  a  fecal  fistula 
forms.  It  is  a  well-known  fact  that  the  loop  of  bowel  does  not  wander  away 
from  the  field  of  operation  until  such  time  as  peristalsis  returns.  We 
consequently  take  advantage  of  this  and  leave  the  suspicious  loop  of 
bowel  immediately  beneath  tiie  opening.  Tins  does  not  prevent  the  oper- 
ator from  inserting  all  the  necessary  sutures  for  the  closure  of  the  abdo- 
men a  few  days  later. 

A  fecal  fistula  occurring  in  this  manner  in  connection  with  a  strangu- 
lated hernia  is  unavoidable.  Indeed,  a  fecal  fistula  may  occur  in  con- 
nection with  resection  of  the  bowel  and  anastomosis  either  by  means  of 
mechanical  appliances  or  with  the  needle  and  thread.  If,  after  resecting 
the  bowel,  symptoms  arise  pointing  to  a  perforation,  and  these  occur  visu- 
ally on  the  third  or  fourth  day,  the  wound  can  be  opened,  the  loop  of  bowel 
always  being  easily  accessible.  In  this  way  tiie  occurrence  of  a  general 
peritonitis  is  prevented,  and  the  life  of  the  patient  may  be  saved. 

A  fecal  fistula  may  also  be  caused  by  the  accidental  wounding  of 
the  bowel  during  operation,  either  because  the  surgeon  is  not  sufficiently 


COMPLICATIONS    IXCIDEXT    'JO   TlIK    RELIEF   OF    HERXIA  IQJ 

familiar  with  the  conditions  present,  or  because  he  is  not  possessed  of  suffi- 
cient skill. 

ACTINOMYCOSIS. 

In  the  autumn  of  1898  I  operated  on  a  case  of  double  oblique  in- 
guinal 'hernia  with  strangulation  on  the  right  side.  For  sutures  I  used 
catgut  which  was  furnished  by  the  hospital  authorities.  About  two  or 
three  weeks  after  the  operation  the  ray  fungus  appeared  in.  the  scar.  The 
interne  mistook  it  for  an  ordinary  skin  infection  and  dressed  the  wound 
for  several  days  before  calling  my  attention  to  it.  The  peculiar  appearance 
of  the  wound  and  its  secretion  at  once  aroused  m.y  suspicion  and  a  micro- 
scopic examination  showed  the  infection  to  be  one  of  actinomycosis.  I 
immediately  operated  again  and  removed  all  the  diseased  structures,  leav- 
ing only  the  peritoneum  and  transversalis  fascia  to  protect  the  bowels. 
I  also  gave  the  patient  rather  large  doses  of  iodide  of  potassium. 

In  spite  of  all  I  could  do,  the  infection  extended  to  the  bow'el,  and  a 
small  fecal  fistula  developed.  I  repaired  the  fistula,  but  it  reappeared 
later.  The  man  was  sent  to  the  almshouse,  with  a  large  pad  over  his  abdo- 
men, and  for  four  or  live  years  afterward,  whenever  I  W'Cnt  there  to  oper- 
ate, he  would  be  one  of  the  first  to  greet  me,  show  me  the  fistula,  and  tell 
me  that  it  was  my  fault.  When  I  last  saw  him  he  still  had  a  small  fistula, 
from  which  there  came  a  slight  discharge  of  fiuid,  but  there  was  no  evi- 
dence of  the  presence  of  the  actinomyces. 

The  source  of  the  infection  in  this  case  is  still  a  mystery  to  me, 
but  I  have  always  suspected  that  the  catgut  sutures  used  during  the  oper- 
ation were  responsible. 

COPROSTASIS. 

Obstruction  of  the  fecal  flow  during  the  existence  of  a  hernia  is  not 
uncommon,  especially  in  old,  incarcerated  cases.  The  onset  of  the  ob- 
struction is  usually  insidious.  The  patient  may  notice  that  the  hernial 
tumor  is  slightly  increased  in  size,  and  on  manipulation  it  feels  quite 
doughy.  The  hernia  continues  to  increase  in  size  until  a  regular  train 
of  symptoms  makes  its  appearance,  such  as  meteorism,  colic,  nausea,  vomit- 
ing, and  local  tenderness.  The  vomiting  may  become  fecal  in  character. 
The  local  application  of  hot  fom.entations,  gentle  massage,-  and  emptying 
the  lower  bowel  may  re-establish  the  fecal  flow%  and  the  patient  is  then 
in  the  condition  in  which  he  was  before  this  complication  occurred.  Som.e- 
times,   however,   strangulation  may  occur,  and  an  operation  be  necessary. 

Besides  these  more  common  complications,  others  are  met  with  oc- 
casionalty.  For  instance,  Neugebauer  {Centralbl.  f.  Innere  Med.,  Nov.  21, 
1896)  reports  a  care  of  incarcerated  inguinal  hernia  in  which  he  discovered 
a  temporary  glycosuria.  The  sugar  was  present  both  before  and  after  the  op- 
eration, although  the  patient  denied  ever  having  had  any  symptoms  of 
diabetes.  The  glycosuria  was  present  for  only  twenty-four  hours.  Ex- 
periments on  animals  showed  that  incarceration  or  obstruction  of  the 
duodenum  or  jejunum  or  other  part  of  the  intestine  from  any  cause,  may 
produce  a  temporary  glycosuria. 


CHAPTER  XVII. 

GENERAL  COMPLICATIONS  FOUND  AT  THE  OPERATION. 

The  complications  that  have  been  encountered  during  operations  for 
hernia  are  so  numerous  that  space  forbids  mentioning  more  than  a  few  of 
them.  Every  surgeon  has  encountered  these  compHcations,  although  ref- 
erence is  not  always  made  to  them  in  the  literature. 

W.  G.  Spencer  (Lond.  Clin.  Soc.  Trans.,  Vol.  30)  rejaprts  .two  cases 
in  which  there  was  an  absence  of  the  internal  ring,,  the  deep  epigastric 
artery  Iving  in  front  of  the  hernia.  Above  the  pubic  spine  there  was  an 
extra-peritoneal  protrusion  of  the  bladder  which  was  closely  adherent  to 
the  sac.  In  both  cases  the  hernia  was  quite  separate  from  the  cord  and 
testicle.  One  patient  was  aged  three  years,  the  other  nineteen.  Both  were 
males.  In  the  first  case  the  sac  contained  fluid  and  omentum.  The  site 
of  the  internal  ring  was  occupied  by  a  slit-like  opening  extending  into  the 
abdomen  the  whole  length  between  the  pillars.  The  sac  was  separated 
easilv  from  the  cord,  but  attached  to  it  on  one  side  appeared  a  translucent 
swelling  which  in  the  attempt  to  separate  it  from  the  sac  was  ruptured, 
and  urine  escaped.  It  was  composed  of  mucous  membrane,  except  at  its 
neck,  through  which  the  finger  was  passed  into  the  bladder.  The  bladder 
pouch  and  the  hernial  sac  were  ligated  and  cut  away  and  the  wound  filled 
with  gauze.  The  pati-ent  recovered.  In  the  second  case  the  sac  contained 
omentum,  which  was  firmly  adherent  to  the  inner  surface  of  the  sac.  No 
internal  ring  or  line  of  demarkation  could  be  found  between  the  sac  and 
the  abdominal  cavity. 

C.  Goulding  Bird  {Trans.  Clin.  Soc.  of  Lond.,  Vol.  17)  reports  two 
cases  of  hernia  en  bissac. 

The  first  patient,  aged  47,  apparently  had  a  strangulated  hernia  on  the 
right  side.  The  tumor  occupied  the  upper  part  of  Scarpa's  triangle,  like 
an  ordinary  femoral  hernia,  but  from  it  a  diverticulum  passed  down  into 
the  adjacent  labium.  Both  sacs  were  dissected  out  and  found  to  have  a 
..  -  .  ^,  common  neck.  The  second  patient,  aged  60,  had  had  a  left  inguinal  her- 
KT  V  nia  for  twenty  years.  She  wore  a  truss  for  ten  years,  when,  thinking 
herself  cured,  she  discarded  the  truss.  For  eight  years  she  had  attacks 
of  vomiting.  She  then  noticed  a  swelling  in  the  left  iliac  region,  which 
increased  in  size,  causing  considerable  discomfort,  but  no  constitutional 
symptoms.  Examination  revealed  two  tumors,  one  protruding  from'  the 
left  external  abdominal  ring,  of  small  size,  and  a  large  mass  extending 
four  inches  above  Poupart's  ligament  subcutaneously.  The  two  sacs  had 
a  common  neck  at  the  internal  abdominal  ring.  Nothing  could  be  differ- 
entiated of  the  aponeurosis  of  the  external  oblique  in  front  of  the  large 
hernia,  it  having  been  destroyed,  apparently,  by  the  pressure  of  the  her- 


Cn 


y^-^C.^fter^Ji^rodel 


PLATE  XXXII. 

Halsted's  Operation  for  Inguinal  Ifernia. 


GENERAL    COMPLICATIONS    FOUND    AT    THE    OPERATION  I97 

nial  sac  which  lay  external  to  it.     The  patient  died  in  two  days.     No  cause 
of  death  was  discovered. 

T.  H.  Kellock  (Lond.  Clin.  Soc.  Trans.,  Vol.  33)  reports  a  case  of 
stricture  of  the  small  intestine  following  a  strangulated  hernia  in  a  boy 
who  had  been  suffering  from  an  irreducible  left  mguinal  hernia  of  about 
the  size  of  an  orange.  The  hernia  did  not  extend  into  the  scrotum.  The 
right  testis  was  in  the  scrotum,  but  the  left  could  not  be  felt.  The  sac 
did  not  contain  fluid,  but  was  occupied  by  a  small  piece  of  discolored 
omentum,  and  about  four  and  a  half  inches  of  small  intestine,  which  was 
almost  black.  The  testicle  was  small  and  undeveloped.  There  was  a  good 
deal  of  fluid  in  the  tunica  vaginalis  which  did  not  communicate  with  the 
abdominal  cavity,  or  with  the  sac  of  the  hernia.  The  cord  was  ligated  and 
the  testicle  removed.  The  inguinal  canal  was  closed  with  two  silk  sutures  - 
and  the  skin  wound  united  with  horsehair.  Thirteen  days  after  the  opera- 
tion the  abdomen  was  a  little  distended  and  slightly  tender.  These  symp- 
toms disappeared  after  proper  catharsis.  During  the  next  three  weeks 
the  boy  suffered  at  times  from  pain  in  the  epigastrium,  and  on  several 
occasions  vomited  undigested  food.  It  was  thought  the  trouble  was  due 
to  adhesions  about  the  bowel.  One  month  afterward  the  abdomen  was 
opened,  and  a  distended,  hypertrophied  intestine  presented  immediately. 
There  was  no  peritonitis.  Lying  in  the  right  iliac  fossa  was  a  loop  of  small 
bowel  to  which  a  tongue-shaped  piece  of  omentum  containmg  large  ves- 
sels was  closely  adherent.  A  lateral  anastomosis  above  and  below  the 
stricture  was  made  by  Halstead's  method.  The  patient  died  fifteen  hours 
afterward.  The  loop  of  the  intestine  which  the  anastomosis  was  designed 
to  put  out  of  action  was  gangrenous.  On  opening  this  part  of  the  bowel 
an  annular  stricture  w^as  found  at  the  apex  of  the  loop  almost  completely 
obstructing  the  lumen  and  involving  about  half  an  inch  in  length  of  the 
bowel.  The  tongue-shaped  piece  of  omentum  was  adherent  to  the  bowel 
immediately  distal  to  the  stricture.  The  hernia  m  this  case  appeared  to  be 
an  acquired  one. 

Marshall  examined  the  records  of  ten  thousand  cases  of  hernia  and  found 
that  nine  hundred  of  them  had  been  complicated  by  an  undescended  testis. 
Coley  found  four  hundred  such  cases  among  9,859  cases  of  hernia.  Eccles 
found  854  instances  among  48,000  cases  of  hernia. 

According  to  Odiorne  and  Simmons,  sarcoma  of  the  testes  occurred 
in  II  per  cent,  of  the  cases. 

The   conjoined   tendon  has   been   found  obliterated   in   27  out  of  366        a  ^ 
cases,  or  7  per  cent.     In  12  cases  in  which  the  conjoined  tendon  was  ah-    ^ 
sent,  recurrence  of  the  hernia  took  place  in  7,  or  over  50  per  cent.,  thus 
emphasizing   the   importance   of   knowing   where   the   conjomed   tendon    is 
and  how  to  protect  it. 

Obliteration  of  the  conjoined  tendon  occurs  in  the  female  about  once     'X-      '" 
in  38  cases ;   in  the  male,  in  about  50  per  cent,  of  the  cases. 

Bloodgood  records  having  met  with  the  following  complications : 
Albumin  and  casts ;  obstruction,  temporary  and  permanent ;  scrotal  ab- 
scess ;    atrophy  of  the  testis ;   hydrocele ;    emphysema  of  the  wound. 


198  GENERAL    COMPLICATIONS    FOUND    AT    THE    OPERATION 

Although  resection  of  a  portion  of  the  bowel  often  is  necessary  in 
operations  on  hernias,  it  is  not  to  be  considered  as  a  complication  in  the 
true  sense  of  the  word.  However,  every  now  and  then  one  meets  with 
a  case  where  a  large  portion  of  bowel  must  be  resected  before  it  is  possi- 
bl  to  reduce  the  hernia.  The  bowel  in  these  instances  is  normal  in  every 
respect.  For  instance,  A.  B.  Mitchell  {British  Medical  Journal,  Sept.  27, 
1902)  reported  the  case  of  a  man,  aged  57,  who  was  operated  on  for  a 
long-standing,  irreducible  hernia,  which  had  given  rise  repeatedly  to  symp- 
toms of  obstruction.  Because  of  its  size  the  hernia  could  not  be  reduced. 
Mitchell  resected  all  of  the  intestine  contained  in  the  sac,  which  was  found 
to  measure  six  feet. 

Monprofit  {Revue  de  Chirurgie,  November,  1899)  reported  a  case  of 
inguinal  hernia  where  during  the  operation  it  was  found  impossible  to 
separate  the  hernial  contents  and  reduce  the  mass,  tie  resected  seven 
feet  and  six  inches  of  the  small  intestine,  and  thirty-two  inches  of  the  large 
intestine,  the  resected  piece  consisting  of  ileum,  cecum,  ascending  colon  and 
half  of  the  transverse  colon.  A  curious  fact  in  this  case  was  that  after 
the  patient  recovered  he  was  unable  to  digest  meat. 

Many  similar  instances  have  been  recorded,  but  these  two  will  suf- 
fice to  direct  attention  to  the  fact  that  in  order  to  reduce  a  hernia  it  may 
be  necessary  to  resect  a  portion  of  the  bowel. 

Perforations  of  the  bowel  contained  in  the  sac  of  a  hernia  have  oc- 
curred quite  frequently,  and  this  emphasizes  the  importance  of  examining 
carefully  all  the  intestine  contained  within. the  sac  before  it  is  returned  to 
the  abdominal  cavity. 

Corner  {Trans.  Loud.  Clin.  Soc.,  Vol.  36)  reports  a  case  of  cellulitis 
of  the  round  ligament  which  was  mistaken  for  a  strangulated  hernia.  For 
four  or  five  days  the  woman  complained  of  pain  in  the  left  groin,  and  a 
small  tumor  was  palpable.  The  pain  increased  in  severity  and  there  was 
some  vomiting  and  constipation.  The  tumor  became  exceedingly  tender  to 
touch.  It  was  situated  over  the  external  abdominal  ring  and  gave  an  im- 
pulse on  coughing.  There  was  a  healthy  round  ligament  at  the  internal 
ring,  but  no  sac.  The  round  ligament  in  the  canal  was  very  much  thick- 
ened, and  evidently  inflamed.  Examination  of  the  incised  mass  disclosed 
a  lymph  gland  breaking  down  in  the  center,   with  surrounding  cellulitis. 

Corner  {Id. )  also  reported  a  case  of  atrophy  of  the  testis  following 
a  kick  in  the  groin  which  gave  rise  to  cellulitis  with  thrombosis  in  the  veins 
of  the  cord.     The  case  was  mistaken  for  one  of  strangulated  hernia. 

A.  E.  Halstead,  of  Chicago,  reported  a  case  of  hydrocele  of  the  canal 
of  Nuck,  which  simulated  a  hernia.  Of  course,  this  is  not  a  complication 
of  hernia,  but  it  is  quite  possible  that  it  might  give  rise  to  hernia,  and  hydro- 
cele may  exist  with  a  hernia. 

Another  very  interesting  case  is  the  one  reported  by  F.  R.  McCreery 
{Medical  Record,  Sept.  9,  1906),  where  a  suppurating  omentum  was  mis- 
taken for  hernia.  About  five  or  six  months  after  the  patient  had  been 
kicked  by  a  horse  in  the  right  lower  quadrant  of  the  abdomen,  a  lump 
appeared  in  the  right  inguinal  region.     When  McCreery  first  saw  the  pa- 


GENERAL    COMPLICATIONS    FOUND    AT    THE    OPERATION 


199 


tient  he  diagnosed  the  case  as  one  of  irreducible  omental  hernia  with  a 
scrotal  abscess  distinct  from  the  hernia  and  of  unknown  origin,  but  pos- 
sibly tuberculous.  At  the  operation  a  number  of  small  collections  of  pus 
were  found.  The  pus  was  odorless  and  no  tubercles  were  observed.  The 
entire  mass  of  omentum  seemed  to  be  riddled  with  abscesses.  About  six 
months  after  the  operation  a  small  hernia  presented  at  the  internal  ring. 
It  was  operated  on  successfully. 


CHAPTER  XVIII. 

RESILTS  OF  HERNIA  OPERATIONS. 

It   is    difficult   to   accurately   estimate   the   ultimate    results      following 
operations   for- the  cure  of  ■hernia.     The  skill  and  the  diagnostic  acumen 
of  the  operator  count  for  so  much  in  determining  these  results.     It  is  obvious 
that  the  results  of  a  poor  operator  cannot  be  as  good  as  those  of  one  who 
is  skilled.     Furthermore,  the  operation  done  in  a  given  case  may  not  have 
been  the  operation  that  was  most  suited  to  the  case  or  that  was  indicated. 
Thereby  the  results  would  be  influenced  very  markedly.    The  results  of  any  / 
one  operator  are  insufficient  to  draw  conclusions  from,  because  the  same  I    ^ 
operation    done    in    similar    cases  by  another     surgeon     would  not  be  fol- ' 
lowed  by  the  same  results.     Therefore,  in  attempting  to  draw  any  conclu- 
sions as  to  the  value  of  an  operation,  it  is  necessary  to  consider  the  results 
obtained  by  'vcry  many  operators  with  all  kinds  of  operations  done  on  all 
kinds  of  cases.     A  mass  of  statistics  is  often  misleading. 

Hilgenreiner  (Beitrdge  zur  Klinische  Chirurgic,  1903-4,  Bd.  12)  re- 
ports 828  operations  performed  in  Woelfler's  clinic  at  Prague,  from  1895 
to  1902,  on  770  patients.  Of  this  number,  471  were  free  hernias,  and  357 
were  strangulated.  For  the  non-strangulated  inguinal  hernias,  446  opera- 
tions were  performed  on  397  patients,  while  for  femoral  hernia  15  opera- 
tions were  performed  on  13  patients. 

The  wound  was  closed  in  various  ways.  In  33  cases  the  cord  was 
transplanted  into  a  slit  in  Poupart's  ligament  (Frey's  method)  ;  in  17 
cases  a  simple  approximation  suture  (Czern3^-Banks)  was  used;  in  a  very 
few  cases  Bassini's  method  was  employed  and  all  the  remaining  cases 
were  operated  on  by  Woelfler's  method.  Hilgenreiner  points  out  the  dif- 
ference between  the  technic  of  Woelfler's  operation  and  that  of  Bassini. 
It  is  surprising  with  what  facility  some  surgeons,  from  a  lack  of  due  con- 
sideration of  the  principles  involved,  make  unsupportable  statements  re- 
garding operative  procedures.  No  less  an  authority  on  hernia  than  Wil- 
liam B.  Coley,  of  New  York,  says  {Progressive  Medicine,  June,  1905,  page 
25)  that  "In  125  cases  the  cord  was  not  transplanted,  but  brought  out  at 
the  lower  angle  of  the  wound,  and  the  external  oblique  being  sutured  to 
Poupart's  ligament,  exactly  the  same  as  in  inguinal  hernia  in  the  female. 
This  method  is  known  in  Germany  as  Woelfler's  method  without  trans- 
plantation of  the  rectus  muscle.  In  this  country  it  is  frequently  known 
as  Ferguson's  method.  W^oelfler's  cases  were  not  reported  until  1895 ; 
Ferguson's  in  1899."     Let  us  follow  this  statement  farther. 

On  page  514,  Vol.  IV,  System  of  Practical  Surgery,  by  E.  von  Berg- 
.  mann,  the  only  mention  made  of  Woelfler's  operation  in  connection  with 


PLATE  XXXIII. 
Halsted's  Operation  for  Inguinal  Hernia. 


RESULTS    OF    HERNIA    OPERATTONS 


20' 


hernia  is,  "In  the  course  of  time  Woelfler  passed  the  testicle  through  the 
space  between  the  two  recti  muscles." 

No  other  author,  even  in  Germany,  makes  any  mention  of  Woelfler's 
operation  in  connection  with  the  cure  of  oblique  hernia. 

In  the  Reference  Handbook  of  the  Medical  Sciences,  Vol.'  IV,  page 
674,  1902,  in  speaking  of  Bloodgood's  method,  this  statement  is  made : 
''This  method  is  superior  to  Woelfler's  in  that  Woeltler  slits  the  ventral 
sheath,  thus  destroying  the  insertion  of  the  internal  oblique  and  trans- 
versalis  muscles  at  that  point." 

If  what  Coley  says  is  true,  then  his  procedure  and  that  of  Woelfler 
are  the  same  as  mine,  but  I  have  failed  to  find  a  corroboration  of  Coley's 
unqualified  statement. 

I  believe  that  since  1902  Woelfler  does  not  transplant  the  cord,  but 
leaves  it  in  its  normal  position,  strengthening  the  anterior  wall  of  the  canal 
by  utilizing  the  rectus  muscle.  I  do  not  do  this  for  oblique  hernia  when 
there  is  a  normal  conjoined  tendon. 

In  the  33  cases  reported  by  Hilgenreiner  that  were  operated  on  ac- 
cording to  the  method  of  Frey  and  Czerny-Banks,  there  were  7  relapses, 
and  in  94  cases  operated  on  by  the  Woelfler  method,  without  the  use  of  the 
rectus,  there  were  eight  relapses.  Coley  does  not  appear  to  grasp  the  vast 
difference  between  the  principles  and  practices  involved  in  the  Czerny- 
Banks  operation  (leaving  the  cord  m  its  normal  bed)  and  my  operation 
(also  leaving  the  cord  undisturbed). 

Transplantation  of  the  cord  is  ably  dealt  with  by  Connell  {American 
Journal  of  the  Medical  Sciences,  March,  1905),  who  considers  the  author's 
view  the  correct  one — namely,  that  the  cord  should  not  be  raised  out  of  its 
bed.  Halsted,  of  Johns  Hopkins  Hospital,  has  discarded  the  transplanta- 
tion of  the  cord.  It  is  stated  by  Connell  that  Woelfler,  in  1892,  was  prob- 
ably the  first  to  suggest  that  a  radical  cure  might  be  effected  without  trans- 
plantation of  the  cord.  E.  W.  Andrews,  in  1895,  suggested  such  an  oper- 
ation, but  did  not  recommend  it.  In  1S99  the  writer  presented  his  method, 
which  he  had  performed  64  times  during  the  previous  eighteen  months. 

Connell  gives  his  reasons  why  the  cord  should  not  be  transplanted, 
while  Coley  {Progressive  Medicine,  June,  1906)  tries  in  vani  to  offset 
these.  In  support  of  his  views,  Coley  says  that  the  only  reason  whv  the 
Bassini  operation  should  be  discarded  in  favor  of  that  of  the  author  Avould 
appear  to  be  "the  final  result".  Coley  says  that  at  the  Plospital  for  Rup- 
tured and  Crippled  Children,  in  New  York,  there  was  only  one  per  cent, 
of  relapses  in  over  seventeen  hundred  cases  operated  on.  This  is  the  best 
apparent  result  ever  obtained  following  Bassini's  operation,  and  the  rea- 
son  is  that  nearlj_aji,i;h.ese  operations  were  done  on  children  under  four- 
teen years  of  age,  and  by  one  operator.  The  results  obtained  from  the 
"writer's -operation  are -.supeirior  to  those  quoted  by  Coley,  and  this  is  par- 
ticularly noticeable  in  view  of  the  fact  that  the  results  are  obtained  after 
operations  done  on  both  die  young  and  the  old  by  more  than  one  operator. 

In  446  cases  operated  on  by  the  Bassini  method  and  reported  by  Gold- 
ner,  there  were  7.1  per  cent,  of  relapses,  all  of  them  in  adults.     In   1,713 


'    { 


204  RESULTS    OF    HERNIA    OPERATIONS 

cases  operated  on  by  the  same  method  and  reported  by  Pott,  there  were 
9.9  per  cent,  of  relapses.  In  450  cases  of  inguinal  hernia  occurring-  in 
adults  and  reported  by  Coley,  there  were  7  relapses,  1.4  per  cent.  Canister 
reports  3  per  cent,  of  relapses  in  100  cases. 

Pott  collected  the  statisiics  of  151  operators  who  employed  the  meth- 
ods of  Bassini  and  Kocher;  and  operated  on  all  kinds  of  hernias  and  found 
that  there  were  96.4  per  cent,  cures.  He  gives  a  mortality  of  0.7  per  cent, 
in  2,401  cases  operated  on  since  1895.  In  86  cases  Halsted  had  9.3  per 
cent,  of  relapses,  8  of  these  occurring  at  the  position  of  the  cord.  The 
veins  were  not  removed  in  these  86  cases.  In  712  cases  operated  on  accord- 
ing to  the  Bassini  method  {Laitcct,  April,  1906),  there  were  2.9  per  cent, 
relapses.  De  Garmo  reports  2.4  per  cent,  of  relapses  in  250  cases,  while 
Hutchison  reports  6.5  per  cent,  of  relapses  in  500  cases.  Thus  it  will  be 
seen  that  in  4,257  cases  operated  on  by  the  Bassini  method,  there  were 
5.3-j-  per  cent,  of  recurrences. 

Deanesly  (B.  M.  J.,  June  17,  1905)  believes  that  the  real  cause  of  her- 
nia lies  in  a  congenital  or  pre-existing  sac,  and  that  the  operation  that 
effectually  removes  the  sac  is  followed  by  radical  cure  in  95  per  cent,  of 
the  cases.  He  believes  that  the  method  of  Kocher  is  the  simplest,  the  most 
rapid  and  the  easiest  to  perform,  and  it  is  the  method  he  employed  in  the 
I  majority  of  his  142  personal  cases.  The  ages  of  his  patients  varied  from 
three  months  to  70  years.  There  was  one  death,  exclusive  of  strangulated 
cases,  occuring  in  an  infant  of  eighteen  months.  Eleven  of  the  operations 
were  for  femoral  hernia.  Six  relapses  were  noted,  all  within  twelve  months 
after  operation. 

Of  299  cases  traced  by  Hilgenreiner  (Bcitr.  z.  kiin.  Chir.,  Bd.  xli,  p. 
373)  that  is,  yy  upward  of  one  year,  the  remainder  from  two  to  seven, 
years,  266  were  permanently  cured.  In  28  a  relapse  was  noticed.  Among 
33  patients  operated  on  according  to  the  methods  of  Frey  and  Czerny 
there  were  7  relapses.  Among  94  patients  operated  on  according  to  Woel- 
fler's  method,  without  transppsition  of  the  rectus  muscle,  there  were  8 
relapses.  Among  163  patients  operated  on  by  Woelfler's  method  with 
transposition  of  the  rectus,  1  t  recurrences  were  noted.  Of  4  Bassini  opera- 
tions done,  2  resulted  in  a  relapse.  Counting  only  the  cases  of  those  pa- 
tients traced  upward  of  two  years  ooerated  on  by  Woeiller's  method  with 
transplantatii  m  of  the  rectus,  there  were  98  with  seven  relapses,  about  7.1 
per  cent.  Fi  <  v's  method  was  employed  successfully  without  relapses  in 
15  cases  of  no" -strangulated  femoral  hernia. 

W.  T.  Bull  and  W.  B.  Coley  {Medical  Record,  Alarch  18,  1905)  re- 
ported 53,686  cases  of  inguinal  and  femoral  hernia  observed  during  the 
period  of  fourten  years,  from  1890  to  1904.  Of  these,  50,961  were  in- 
guinal, and  2,725  were  femoral  hernias.  One-third  of  these,  15,375,  oc- 
curred in  children  under  fourteen.  They  performed  fifteen  hundred  opera- 
tions for  the  radical  cure  of  herriia.  JVith  the  excepiion  of  t-a'enty  opera- 
tions, all  have  been  in  children  under  the  age  of  fouriecii  year^\  The 
operative  cases,  it  is  claimed,  represent  the  worst  cases  of  rupture,  the 
largest,  and  those  of  longest  duration.     There  were  4  deaths  in  the   1,500 


PLATE  XXXR'. 
Fowler's  Operation  for  Inguinal  Hernia. 
Deep   epigastric   vessels   ligated   and  posterior   wall  of   inguinal   canal 


livided. 


RESULTS    OF    HERNIA    OPERATIONS  20/ 

Operations,  or  a  mortality  of  less  than  three-tenths  of  one  per  cent.  Of  the 
1,500  operations,  1,435  were  for  inguinal  hernia,  39  for  femoral,  13  for 
umbilical,  8  for  ventral,  2  for  congenital  hernia  of  the  umbilical  cord,  2 
for  epigastric,  and  1  for  lumbar  hernia;  13  were  strangulated,  and  1,487 
were  not  strangulated.  The  great  majority  of  operations  for  inguinal 
hernia  were  performed  according  to  Bassini's  method,  with  the  substitu- 
tion of  absorbable  suture,  kangaroo  tendon,  for  silk.  There  were  6  re- 
lapses among  1,076  Bassini  operations,  and  5  in  125  cases  in  which  the 
cord  was  not  transplanted. 

From  a  study  of  91  operations  done  for  various  forms  of  hernia,  O. 
Horwitz  concluded  that  no  one  method  of  attempt  at  radical  cure  is  ap- 
plicable to  every  variety  of  hernia.  The  Bassini  method  is  suitable  to  a 
large  majority;  the  Bloodgood  method  in  cases  in  which  there  is  present 
a  large  abdominal  ring,  or  a  weak  or  atrophied  conjoined  tendon.  He 
says  that  the  relief  of  special  forms  and  conditions  depends  on  the  ingenuity 
of  the  surgeon  in  selecting  the  operation  indicated  by  the  conditions  present. 

John  O'Connor  {Lancet,  May  31,  1902)  reported  350  operations,  140 
of  which  were  done  according  to  Halsted's  method,  12  accordmg  to 
Kocher's,  and  90  by  Bassini's  and  other  methods.  He  observed  that  atrophy 
of  the  testes  and  orchitis  frequently  followed  the  Halsted  method,  and  he 
thinks  the  transplantation  of  the  cord  is  very  questionable  surgery.  In 
his  experience  Kocher's  method  has  given  the  best  results. 

In  the  Johns  Hopkins  Hospital  Reports,  Vol.  VII,  Bloodgood  reports 
on  459  operations  done  from  1889  to  1899.  Of  268  cases  in  which  a  typical 
Halsted  operation  was  done,  242  healed  by  primary  union.  The  result  was 
perfect  in  208  cases,  and  there  were  only  6  recurrences  and  one  death. 
There  was  slight  weakness  and  scar  in  four  cases,  and  25  were  not  traced. 
There  was  only  one  complete  recurrence  after  Halsted's  operation  Avhere 
primary  union  took  place. 

Of  39  cases  of  inguinal  hernia  in  the  female  operated  on  at  the  Johns 
Hopkins  Hospital,  11  were  lost  sight  of,  and  in  the  remainder  there  was 
only  one  recurrence.  Between  1891  and  1900,  Coley  operated  on  119 
cases  of  inguinal  hernia  in  the  female,  71  of  which  occurred  in  children 
under  fourteen  years  of  age,  and  not  a  single  relapse  was  observed. 

W.  B.  De  Garrno,  in  1901,  stated  that  among  611  operations  for  in- 
guinal hernia  by  Bassini's  method,  there  were  only  8  recurrences.  In 
Carle's  clinic,  from  1889  to  1899,  1,120  operations  were  done  according 
to  Bassini's  method,  280  according  to  Kocher's  method.  Of  840  cases 
that  were  traced,  only  48,  or  5.71  per  cent.,  showed  a  recurrence. 

Galeazzi  collected  1,334  cases  operated  on  by  Bassini's  method,  with 
2.16  per  cent,  recurrence.  Erdmann  (Jour.  Am.  Med.  Assn.,  Alarch  12. 
1904)  reported  26  cases  of  strangulation  in  inguinal  hernia,  with  5  dea.ths, 
and  G.  T.  Vaughan  {Medical  Neivs,  December  24,  1904)  reported  25  cases 
with  6  deaths,  a  mortality  of  24  per  cent.  At  The  Johns  Hopkins  Hospital 
64  operations  for  strangulated  hernia  were  performed  from  1889  to  1899, 
with  19  deaths,  or  29.68  per  cent,  mortality.     Gibson  in  his  collective  sta- 


208  RESULTS    OF    HERNIA    OPERATIONS 

listics  covering  ten  years,  from  1888  to  1898,  reported  226  resections  of 
gangrenous  intestines,  with  a  mortality  of  26  per  cent. 

As  regards  permanent  results,  that  is,  sound  at  least  two  years  after 
operation,  O.  Pott's  statistics  (Deutsche  Zeitschrift  fi'ir  Chirurgie,  Novem- 
her,  1903")  siiow  82  per  cent,  for  inguinal  hernia,  70.5  per  cent,  for  femoral 
hernia,  and  55  per  cent,  for  ventral  hernia. 

Adatanowitsch  (Beitrdge  zuv  KUnische  Chirurgie,  1902)  publishes 
a  very  interesting  table  of  comparison  of  results  of  observations  done  by 
Bassini's  and  Kocher's  methods  respectively.  Of  2,032  cases  operated  by 
Bassini's  method,  74  relapsed,  3.6  per  cent.  Of  528  cases  operated  by 
Kocher's  method,  19  relapsed,  3.8  per  cent. 

'^.  Goldner  {Archiv  f.  Klin.  Chir.,  Vol.  68,  No.  i)  reports  800  opera- 
tions done  by  Bassini's  method.  He  found  that  in  466  of  this  number  ex- 
amined from  two  to  six  and  one-half  years  after  operation,  there  were  35 
relapses,  or  7.5  per  cent.    There  v/ere  3  deaths  among  the  800  cases. 

W.  B.  De  Garmo  reported  no  femoral  hernias,  28  of  which  were 
strangulated.  Only  i  death  occurred,  the  patient,  a  wom.an,  aged  70, 
having  a  strangulated  hernia  and  an  intestinal  perforation.  Exhaustion 
was  the  cause  of  death.  There  was  only  one  actual  recurr(?nce,  eight  months 
after  operation,  in  a  w^oman  of  75.  All  of  these  patients  were  operated  on 
according  to  De  Garmo's  method. 

A  study  of  the  results  obtained  by  operation  on  500  patients  led  Hutch- 
ison to  draw  the  following  conclusions. 

I.  In  all  but  the  simplest  cases  in  children  it  is  best  to  open  up  the 
canal  and  to  narrow  it  by  deep  sutures ;  2,  suturing  the  conjoined  tendon 
to  Poupart's  ligament  behind  the  cord  by  a  series  of  interrupted  sutures 
is  probably  the  best  method  of  narrowing  the  canal ;  3,  when  the  con- 
joined tendon  is  deficient,  in  all  recurrent  cases,  and  in  inguinal  hernia  in 
women  the  canal  should  be  obliterated ;  4,  kangaroo  tendon  is  admirably 
adapted  for  the  suture  material,  silver  wire  being  probably  the  worst; 
5,  recurrence  of  the  hernia  in  situ  may  possibly  take  place  at  any  length 
of  time  after  the  operation,  but  if  tAvo  years  be  adopted  as  the  limit  it 
should  not  occur  in  more  than  from  5  to  8  per  cent. ;  and  6,  the  develop- 
ment of  a  hernia  at  another  site  after  operation  may  be  expected  in  a  pro- 
portion of  cases  at  least  as  large  as  that  just  given. 


CHAPTER  XIX. 

RESILTS  OF  OPERATIONS  FOR  STRANGULATED 

HERNIA. 

Weyprecht  {Archiv  f.  Klinische  Chirurgie,  No.  i,  Bd.  Ixxi)  reports 
observations  made  from  June,  1890,  to  June,  1900,  at  the  City  Hospital  in 
the  clinic  of  Professor  Korte.  Of  402  cases  treated,  70  were  reduced  with- 
out operation ;  307  patients  were  operated  on ;  4  were  admitted  moribund 
and  no  operation  was  performed,  and  one  patient  died  without  operation, 
a  small  strangulated  femoral  hernia  having  been  overlooked.  There  were 
57  dealhs  among  397  cases  of  incarcerated  hernia,  a  mortality  of  14.4  per 
cent.  Of  254  non-gangrenous  cases,  230  (90.6  per  cent.)  were  cured; 
23  of  the  patients  died  (9  per  cent.),  and  one  patient  left  the  hospital  im- 
mediately after  operation  and  was  lost  sight  of.  Of  73  gangrenous  cases, 
39  were  cured  (53.4  per  cent.),  and  34  patients  died  (46.6  per  cent.). 

Of  7  cases  of  strangulated  hernia  occuring  in  5  males  and  2  females, 
aged  six  months,  there  were  2  fatalities,  28.6  per  cent.  Among  six  pa- 
tients, males,  aged  six  months  and  ten  years,  there  were  no  fatalities. 
Among  61  cases  of  strangulation,  occuring  in  30  males  and  31  females, 
from  II  to  40  years  old,  there  were  two  fatalities,  3.26  per  cent.  Am.ong 
250  cases,  occurring  in  60  males  and  190  females,  aged  from  41  to  80 
years,  there  were  52  fatalities,  20.8  per  cent.  Of  three  females,  over 
eighty  years  of  age,  one  died,  a  mortality  of  33  1-3  per  cent. 

The  total  mortality  after  operation  was  17.4  per  cent.;  loi  deaths 
occurred  among  men  and  226  among  women.  Gangrene  was  present  in 
12  of  the  former  and  in  61  of  the  latter.  The  greatest  number  of  deaths 
occurred  between  the  ages  of  41  and  80 — 20.8  per  cent  (52  deaths  out  of 
250  cases)  ;  7  cases  up  to  six  months  with  two  deaths;  three  over  So  with 
only  one  death. 

The  fifth  decade  showed  the  largest  number  of  operations — 81,  vvith  12 
deaths — 14.8  per  cent.  Incarcerated  femoral  hernia  was  observed  more 
frequently  in  women  than  in  men — 174  against  18.  Inguinal  hernia  oc- 
curred twice  as  often  in  men  as  in  women — yy  to  36.  The  right  side  was 
the  seat  of  incarceration  in  71  inguinal  and  133  femoral  hernias ;  the  left 
in  42  inguinal  and  70  femoral.  Ninety-two  (28  per  cent.)  of  the  patients 
had  worn  a  truss,  while  42  (12.8  per  cent.)  were  not  aware  of  the  pres- 
ence of  a  hernia  until  strangulation  occurred.  Strangulation  of  two  her- 
nias in  one  person  was  seen  once.  The  duration  of  the  incarceration  always 
had  an  unfavorable  effect  on  the  result  of  operation. 

With  reference  to  the  contents  of  the  sac,  omentum  alone  was  found 
^^y  times — in  17  inguinal  and  20  femoral  hernias.     A  loop  of  small  intes- 


tine  was  found  in  126  oases;  several  loops  were  found  in  7  cases:  Meckel's 
diverticulum,  twice:  small  intestine  and  omentum  in  5  cases;  large  intes- 
tine, once;  large  and  small  intestine,  six  times;  large  intestine  and  omen- 
tum, twice;  large  and  small  intestine  and  omentum,  once.  Appendices 
epiploic^  caused  strangulation  in  four  cases.  The  vermiform  process  had 
become  incarcerated  in  12  cases.  In  nine  of  the  latter  the  patients  were 
over  57  years  of  age,  and  in  all  of  these  hernia  had  been  acquired  late  in 
life.  In  175  cases  the  patients  made  an  uninterrupted  recovery;  in  32 
complications  arising  from  the  respiratory  organs  were  noted,  with  5 
deaths.  Peritonitis  was  the  cause  of  death  in  but  i  of  23  fatal  cases. 
In  the  majority  of  the  cases  death  occurred  not  as  the  result  of  the  opera- 
tion, but  in  consequence  of  concomitant  and  unavoidable  bodily  conditions. 

Regarding  the  contents  of  the  hernial  sac  in  the  gangrenous  cases, 
the  small  intestine  alone  was  found  in  52  cases ;  small  intestine  and  omen- 
tum in  15 ;  omentum  and  large  intestine,  omentum,  large  intestine  and 
small  intestine,  small  intestine  and  bladder  in  i  case  each.  The  vermiform 
process  was  found  3  times. 

Fuchsig  and  Haim  {Deutsche  Zeitschr.  f.  Chir.,  Vol.  Ixix,  No.  5  and 
6)  report  175  cases  of  strangulated  hernia  observed  during  ten  years.  Of 
these  97  were  inguinal ;  62  femoral ;  14  umbilical  and  i  each  obturator  and 
ventral.  The  presence  of  a  congenital  hernial  sac  could  be  proven  in  17 
cases  of  inguinal  hernia.  Of  the  inguinal  hernias,  97  occurred  in  males  and 
7  in  women ;  femoral,  62  in  women  and  5  in  men ;  umbilical,  14  in  women 
and  onlv  i  in  a  male  subject.  Incarceration  was  noticed  on  the  right  side 
in  63  per  cent,  each  of  the  inguinal  and  femoral  hernias.  In  the  great 
majority  of  the  cases  the  strangulation  was  primary,  although  in  20  in- 
guinal, 7  femoral  and  4  umbilical,  repeated  incarcerations  had  preceded 
admission  to  the  hospital.  In  only  two  (umbilical)  had  a  radical  operation 
been  performed  previously.  Thirty-seven  cases  w^ere  cured  by  taxis.  In 
135  cases  operation  was  performed,  and  in  the  majority  of  the  inguinal 
hernias  Bassini's  method  was  employed.  Primary  resection  was  done  14 
times  with  a  mortality  of  54  per  cent.  (17  cases).  Peritonitis  was  the 
cause  of  death  in  all  the  fatal  cases  of  resection.  The  total  m.ortality  was 
20  per  cent. — 35  deaths  in  170  cases.  Of  these  135  were  operated  on,  with 
32  deaths — 23.7  per  cent.  Of  the  37  cases  in  which  taxis  was  employed  i 
died.  Three  patients  refused  operation.  There  were  70  cases  of  inguinal 
hernia  with  12  deaths  (17.1  per  cent.)  ;  51  crural  hernias,  with  12  deaths 
(23.5  per  cent.)  ;  13  umbilical  hernias,  with  7  deaths  (53  per  cent.)  :  one 
case  of  obturator  hernia  with  one  death. 

O.  Pott  {Deutsche  Zeitschr.  f.  Chir.,  Nov.,  1903)  shows  that  the  mor- 
tality of  all  radical  operations  for  hernia  thus  far  performed  is  nearly  i 
per  cent.,  0.9  per  cent.,  being  the  greatest  in  ventral  hernia,  w'hile  in 
inguinal  hernia  it  is  about  the  same  as  is  the  general  mortalitv.  The  total 
mortality  for  the  last  seven  or  eight  years  is  far  more  favorable,  being 
but  one-half  of  one  per  cent. ;  the  operations  for  femoral  hernia  showing 
the  greatest  number  of  deaths.     For  inguinal  hernia  the  mortality  is  two- 


PLATE  XXXV. 

Fowler's  Operation  for  Inguinal  Hernia. 

Cord   placed   in   peritoneal    cavity   and   gap   sutured. 


RESULTS    OF    OPERATIONS    FOR    STRANGULATED    HERNIA  213 

thirds  of  one  per  cent.,  instead  of  almost  two  per  cent.,  as  it  was  ni  tlie 
first  two  decades  of  modern  surgery. 

As  regards  the  permanent  results,  that  is,  sound  at  least  two  years 
after  operation.  Pott  shows  82  per  cent,  for  inguinal  hernia,  70.5  per  cent. 
for  femoral  hernia,  and  55  per  cent,  for  ventral  hernia.  The  results  in 
children  (up  to  14  years),  including  all  varieties  of  hernia,  were  560  per- 
manent cures,  84  relapses,  4  doubtful — 96.4  per  cent.  In  individuals  over 
fifty  years  of  age,  there  were  259  permanent  cures,  173  recurrences,  to 
doubtful — 58.6  per  cent. 

As  to  the  best  method  of  operatmg,  Pott  shows  Kocher's  transplanta- 
tion method  and  the  Bassini  method  to  be  about  equally  efficient.  In 
femoral  hernia,  ligature  and  extirpation  of  the  sac  and  suture  of  the  mouth 
of  the  hernial  ring  have  given  the  best  results — 76.5  per  cent. 

AV.  Thorburn  {British  Medical  Journal,  April  25,  1903)  analyzed  no 
operations  for  strangulated  hernia,  in  which  the  mortality  was  24.54  per 
cent. 

Kennedy  (B.  M.  J.,  Oct.  i,  1904)  gives  the  results  of  operation  in 
103  cases  operated  on  more  than  a  year  ago;  96  of  the  patients  v:ere  males, 
7  females.  The  youngest  patient  (for  strangulation)  was  six  months  of 
age,  the  oldest  74  years.  Twenty  operations  were  done  in  patients  from 
six  months  to  three  years  of  age.  In  45.6  per  cent,  the  sac  was  of  the  con- 
genital type.  Six  cases  were  cecal  hernias  and  one  case  was  a  hernia  of 
the  ovary.  There  was  only  one  death,  occurring  six  weeks  after  operation 
from  tuberculous  meningitis. 

The  older  cases,  20  in  number,  were  operated  on  after  Macewen's 
method;  11  were  traced,  w^ith  two  relapses.  Seventy  cases  were  operated 
on  by  Kenedy's  method ;  54  were  traced  from  one  to  five  years,  with  only 
I  relapse. 

The  late  Dr.  T.  H.  Alanley  {Phna.  Med.  Jour.,  March  16,  and  2t,,  1901) 
reviews  the  literature  of  strangulated  and  gangrenous  hernia.  Heuser,  of 
Paris,  recorded  (1861-1865)  227  patients  operated  on,  with  172  deaths, 
a  mortality  of  75.08  per  cent.  Tschering,  in  1888,  reported  524  cases  with 
a  mortality  of  29  per  cent.  McCready  collected  the  cases  operated  from 
1869  to  1888,  showing  that  the  mortality  was  36  per  cent. 

Hennegeler,  in  1896,  reported  296  kelotomies  with  23.02  per  cent, 
mortality.  Bouchard,  in  1896,  reported  86  kelotomies  with  17.97  per  cent, 
mortality.  Hagedorn  collected  170  cases,  from  1883  to  1890,  with  14  per 
cent,  mortality.  Gibson  collected  226  cases  of  primary  enterorrhaphies  with 
58  deaths,  a  mortality  of  26  per  cent. 

Croft,  in  1896,  performed  13  colostomies,  none  of  the  patients  dying. 
Czerny  and  Hahn  found  the  mortality  of  primary  resection  to  be  47  per 
cent. ;  ^Mikulicz,  2)^  per  cent. ;  Bouchard,  36  per  cent.  Ziedler  gives  re- 
section 49  per  cent,  and  colostomy  74  per  cent,  mortality.  Frank  gives  the 
mortality  of  resection  as  48  per  cent.,  and  of  colostoni}-  as  80  per  cent. 
Maydl  gives  22  per  cent,  for  resection,  and  \\^allace  gives  25  per.  cent.,  and 
90  per  cent  for  colostomy.  The  mortalitv  for  resection  is  given  as  38  per 
cent,  by  Makins,  37  per  cent,  by  Bouilly.     Korte  found  the  mortality  of 


214  RESULTS    OF    OPERATIONS    FOR    STRANGULATEb    HERNIA 

colostomy  57  per  cent. ;  Friederichshain,  '](>  per  cent. ;  Poulsen,  86  per 
cent.,  and  Lockwood,  88  per  cent. 

In  1894  the  combined  statistics  of  Czerny,  Reidel,  Kocher,  Hagedorn, 
and  Hahn  gave  64  cases  of  primary  resection  with  32  deaths,  a  mortahty 
of  50  per  cent.  ]\IiknHcz  had  94  cases  of  colostomy  with  72  deaths,  76.6 
per  cent,  mortality.  Hofmeister  had  167  cases,  Avith  loi  deaths,  60.5  per 
cent,  mortality.  ^Mikulicz  had  68  cases  of  resection,  with  32  deaths,  47.1 
per  cent,  mortality;  Hofmeister  had  214  cases  of  resection  with  99  deaths, 
46  per  cent,  mortality. 

In  280  herniotomies  done  by  Czerm-  from  1877  to  1900,  the  mortality 
was  18.5  per  cent.  Arranged  according  to  procedure,  the  mortality  was, 
reposition  of  intestine  intact,  216  cases,  with  2'j  deaths,  or  11  per  cent.; 
colostomy,  22  cases,  with  15  deaths,  67  per  cent.;  primary  resection,  28 
cases,  with  9  deaths,  33  per  cent.  Adding  to  this  list  2  cases  of  double 
resection  with  fatal  termination,  there  are  52  gangrenous  hernias  with  2K> 
deaths,  a  mortality  of  50  per  cent. 

B.  M.  Ricketts  {American  Medicine^  ]^\Iay  4,  1901)  states  that  in  in- 
guinal hernia  the  average  of  recurrence  for  34  operators  will  be  5.58  per 
cent,  in  6,027  cases.  He  states  that  the  preferred  operations  arc  the  Marcy- 
Bassini,  ]\Iacewen,  Halsted,  Ferguson,  Andrews,  Phelps  and  Blake. 


CHAPTER  XX, 

RESILTS  FROM  FERGISON  METHOD. 

PERSONAL  EESTJLTS. 

In  twenty-four  years  (1892-1906)  I  have  operated  for  the  cure  of 
hernia  in  twenty  different  hospitals  by  ten  differenc  methods  and  eight 
modifications  of  these  methods.  The  evolution  of  my  method — the  typic  or 
anatomic  operation — for  the  cure  of  oblique  inguinal  hernia  is  based  on  an 
experience  derived  from  the  clinical  study  of  654  cases  of  hernia,  489  of 
which  were  of  the  inguinal  variety.  In  these  489  cases  I  did  543  operations. 
There  were  23  cases  of  direct  inguinal  hernia,  and  466  cases  of  oblique 
inguinal  hernia.     These  489  cases  can  be  further  subdivided  as  follows : 

(i)   Congenital  and  acquired,  31S  cases. 

(2)  Infantile,  2  cases. 

(3)  Interstitial,  (a)  preinguinal,  2  cases;  (bj  inguino-interstitial 
(Goyrand's  hernia),  2  cases. 

(4)  Inguino-crural  (ITolthouse's  hernia),  i  case. 

(5)  Traumatic,  2  cases. 

(6)  Post-operative  (vasectomy  for  tuberculosis  of  the  vas),  i  case. 

(7)  Sliding  (a)  sigmoid,  one  case;  (bj  cecum,  4  cases;  (c)  cecum 
and  appendix,  2  cases. 

(8)  Incarcerated,  6  cases. 

(9)  Strangulated,  28  cases. 

In  this  last  series  of  cases  there  were  five  deaths;  (a)  suppurating  at 
time  of  operation,  i  case;  (b)  gangrenous,  colostomy  done,  2  cases;  (c) 
resection  (double  hernia),  2  cases,  one  patient  operated  on  by  the  open 
method,  and  the  other  by  AIcBurney's  method. 

(10)  Twelve  unclassified  cases  of  inguinal  hernia  (early  work,  rec- 
ords not  complete). 

(11)  Double  inguinal,  46  cases    (92  operations). 

(12)  3>Iultiple  hernias,  20  cases;  (a)  oblique  inguinal  and  femoral, 
8  cases;  (b)  oblique  inguinal  and  umbilical,  2  cases;  (c)  oblique  inguinal 
and  ventral,  3  cases;  (d)  oblique  inguinal,  femoral  and  obturator,  i  case; 
(e)  oblique  and  direct  inguinal,  2  cases;  (f)  double  direct,  2  cases;  (g) 
6  hernias  in  one  patient;    (h)   ten  hernias  in  one  patient. 

There  were  44  cases  of  femoral  hernia  not  including  those  in  which 
both  a  femoral  and  an  inguinal  hernia  existed.  These  cases  Avere  divided 
as  follows : 

(i)  Saphenous,  26  cases. 

(2)  Anterior  (Velpeau's),  2  cases. 

(3)  Ascending  subcutaneous,  3  cases. 


2l6  RESULTS    FROM    FERGUSON    METHOD 

(4)  Strangulated,  10  cases. 

(5)  Double  femoral   (6  operations),  3  cases. 

There  were  6  cases  of  epigastric  hernia,  4  congenital  and  2  acquired. 
Fifty-two  cases  of  umbilical  hernia  were  divided  as  follows : 
(i)  Omphalocele,  42  cases. 
{2}  Funicular  hernia,  i  case. 

(3)  Interstitial  hernia;  (aj  subcutaneous,  4  cases;  (b)  subperitoneal, 
I  case. 

(4)  Strangulated,  4  cases  with  two  deaths. 

There  were  60  instances  of  ventral  hernia,  as  follows : 
(i)   Hernia  in  the  Hnea  alba,  48  cases;    (a)    congenital,   1   case;    (b) 
acquired,  2  cases;    (c)  post-operative,  45  cases. 

(2)  Hernia  in  the  linea  semilunaris;  (a)  acquired,  i  case;  (b)  post- 
operative, 3  cases. 

(3)  Hernia  through  the  rectus  muscle,  traumatic,  i  case;  post-opera- 
tive, 7  cases;  (a)  following  cholecystectomy,  i  case;  (b)  following  appen- 
dectomy, 4  cases;    (c)  following  salpingotomy,  2  cases. 

There  were  only  two  cases  of  lumbar  hernia  and  one  case  of  obturator 
hernia  in  which  there  was  also  a  femoral  and  an  inguinal  hernia.  The 
obturator  hernia  was  not  discovered  until  after  it  had  become  strangulated. 

There  was  one  case  each  of  the  following  varieties  of  hernia :  Left 
duodenal  hernia;  hernia  through  the  transverse  meso-colon  into  the  lesser 
cavity  of  the  peritoneum ;  vesico-rectal  hernia ;  vesico-inguinal  hernia ; 
diaphragmatic  hernia,  and  one  instance  (referred  to  me  by  Dr.  Albert 
Peacock)   of  hernia  into  Douglas'  pouch. 

In  this  whole  series  of  cases  there  were  21  recurrences,  (a)  After  the 
typic  (author's)  operation,  new  direct  hernias,  4  cases;  (b)  after  Bassini's 
operation  and  its  modifications,  11  cases;  after  McBurney's  operation,  i 
case ;    after  Kocher's  operation,  2  cases ;    after  other  methods,  3  cases. 

I  have  performed  my  own  operation  356  times,  with  only  one  death, 
from  nephritis.  The  patient,  a  male,  24  years  of  age,  was  feeble-minded 
and  physically  undeveloped.  He  had  two  enormous  congenital  inguinal 
hernias,  both  of  which  were  operated  at  one  sitting.  He  took  the  anesthetic 
very  badly  (first  chloroform,  then  ether).  Fie  had  suppression  of  urine 
immediately  following  the  operation.  There  was  no  clinical  evidence,  nor 
anything  in  his  personal  history,  that  pointed  to  kidney  disease.  He  never 
fully  regained  consciousness  after  the  operation,  and  died  on  the  fourth 
day. 

In  his  case  I  found  on  the  right  side  a  very  singular  arrangement  of 
the  internal  oblique  muscle.  Its  fibers  were  directed  obliquely  upward 
and  inward  toward  the  umbilicus.  There  was  a  normal  origin  at  Poupart'.-' 
ligament,  but  its  insertion  at  the  border  of  the  rectus  muscle  was  at  least 
two  inches  higher  than  the  level  of  the  internal  abdominal  ring.  After 
ablating  the  sac  and  tightening  up  the  slack  in  the  transversalis  fascia,  so 
as  to  form  a  new  ring,  I  sutured  the  free  border  of  the  internal  oblique 
muscle  to  the  edge  of  the  rectus  muscle,  and  then  closed  the  wound  as 
usual. 


PLATE  XXXVI. 
Fowler's   Operation   for    Inguinal    Hernia. 
Showing  position  of  cord.     Annals  of  Surgery — Year  Book — Gould,   1899. 

Fig.  30.     Page  326. 
I.  Transversalis  fascia.     2.  Peritoneum.     3.  Cord.     4.  External  oblique 
muscle.     5.  Internal  oblique  muscle.     6.  Transversalis  muscle    7.  Conjoined 
tendon.    8.  Poupart's  ligament. 


RESULTS    FROAI    FERGUSON     METHOD  219 

It  is  a  source  of  much  satisfaction  to  be  able  to  state  that  in  the  356 
typic  operations  performed  by  me  there  is  no  known  recurrence  after  more 
than  two  years  in  225  cases  that  I  have  been  able  to  trace.  Four  patients 
returned  claiming  that  the  hernia  had  recurred,  but  on  examination  I  found 
that  there  was  not  a  return  of  the  oblique  inguinal  hernia,  for  which  the 
operation  was  done,  but  that  there  was  in  each  case  a  hernial  protrusion 
in  Hesselbach's  triangle — a  direct  hernia.  To  cure  this  condition  I  oper- 
ated according  to  Bloodgood's  method.  If  I  had  detected  at  the  time  of  the 
original  operation  that  the  conjoined  tendon  in  these  cases  was  deficient, 
and  had  combined  Bloodgood's  method  with  my  own,  I  am  convinced  that 
the  direct  hernia  would  not  have  occurred.  When  there  is  a  weakness  in 
the  lower  inguinal  region,  there  is  also  a  bulging  of  the  internal  inguinal 
fossa,  either  external  or  internal  to  the  obliterated  hypogastric  artery — 
the  two  sites  at  which  a  direct  hernia  may  form. 

A  weakness  in  this  fossa  is  best  detected  by  passing  the  index  linger 
through .  the  internal  ring  into  the  abdominal  cavity  and  down  into  the 
fossa  in  the  triangle  of  Hesselbach,  and  creating  a  forward  pressure  in 
the  suspected  weak  place.  The  finger  or  fingers  (I  use  two  fingers  for 
this  exploration)  will  detect  a  laxness  of  the  peritoneum  and  the  trans- 
versalis  fascia  in  this  region  when  the  conjoined  tendon  is  deficient.  This 
is  reason  enough  for  the  surgeon  to  take  some  steps  in  his  operative  pro- 
cedure to  protect  the  lower  as  well  as  the  upper  angle  of  the  wound. 

The  statistics  of  W.  B.  Coley,  of  New  York,  do  not  bear  on  this  point 
at  all,  because  children  never  have  direct  hernias.  His  statistics  are  based 
principally  on  operations  done  on  children  under  fourteen  years  of  age. 
And  so  far  as  relapses  at  the  internal  ring  are  concerned,  it  is  rare  indeed 
to  have  a  recurrence  after  herniotomy  in  children,  because  of  the  muscular 
development.  It  is  futile  and  unwise  to  give  any  consideration  v/hatever 
to  statistics,  however  honestly  and  faithfully  compiled,  based  on  one  line 
of  work  on  children  in  the  determination  of  the  most  useful  method  of 
curing  inguinal  hernia  by  operation. 

The  method  which  is  most  applicable  in  the  case  of  hernia  in  children 
is  not  always  the  most  suitable  one  in  the  case  of  hernia  occurring  in  the 
adult.  At  the  same  time,  however,  any  method  that  is  applicable  for  the 
cure  of  an  oblique  inguinal  hernia  in  the  adult  will  produce  even  better 
results  in  the  case  of  children. 

There  are  three  methods  by  means  of  which  the  triangle  of  Hesselbach 
may  be  protected  from  becoming  the  seat  of  a  direct  hernia,  either  external 
or  internal. 

(i)  By  making  use  of  the  rectus  muscle  according  to  the  procedure 
devised  by  W.  S.  Halsted,  or  that  devised  by  John  Bloodgood.  The  credit 
for  suggesting  this  method  is  due  Halsted.  I  prefer  using  the  rectus  mus- 
cle itself  instead  of  its  sheath. 

(2)  Anterior  transplantation  of  the  cord,  either  according  to  Eassini's 
or  Halsted's  method.  It  is  immaterial,  however,  whether  the  cord  is 
brought  out  above  or  below  the  aponeurosis  of  the  external  oblic|ue  mus- 


220  RESULTS    FROM    FERGUSON     METHOD 

cle.  Either  method  is  to  be  condemned.  I  have  shown  that  anterior  trans- 
plantation of  the  cord  should  never  be  performed. 

(3)  Posterior  transplantation  of  the  cord,  either  according  to  Fowler's 
method,  where  the  cord  is  placed  intra-peritoneally,  or  according  to  the 
author's  method,  in  which  the  cord  is  placed  between  the  peritoneum  and 
transversalis  fascia.  In  the  case  of  either  method  the  deep  epigastric  ves- 
sels must  be  cut  and  ligated  with  catgut  ligatures.  Either  method  is  suit- 
able when  an  oblique  and  a  direct  hernia  exists,  or  when  the  hernia  is  com- 
plicated by  a  non-descended  testis. 

If  the  surgeon  bases  his  technic  of  operation  for  the  cure  of  inguinal 
hernia  on  the  transplantation  of  the  cord,  it  is  well  for  him  to  transplant  it 
backward  instead  of  forward,  thus  savmg  himself  the  conviction  of  being 
the  cause  of  at  least  six  per  cent,  of  recurrences  at  the  upper  angle  of  the 
wound. 

COMPLICATIONS. 

I  have  had  three  cases  in  w^hicli  atrophy  of  the  testicle  occurred  and 
one  case  of  gangrene  of  the  testicle.  In  one  case  the  atrophy  followed  as 
the  result  of  suppuration  of  the  cord.  Among  the  356  operations  done, 
there  were  only  six  cases  of  stitch-hole  abscess  and  two  cases  of  deep  sup- 
puration. There  were  two  cases  of  hematoma  and  six  of  secondary  wound 
secretion.  In  two  instances  it  was  necessary  to  remove  the  testes  at  the 
time  of  operation.  These  were  cases  of  strangulated  hernia.  In  three  cases 
of  strangulated  inguinal  hernia  general  peritonitis  followed,  and  also  in 
two  cases  of  femoral  hernia.    These  five  patients  died. 

RESULTS  OF  AUTHOR'S  OPERATION  DONE  BY  OTHERS. 

W.  J.  and  C.  H.  Mayo  have  operated  on  1,244  cases  of  inguinal  hernia 
by  the  author's  method.  Of  this  number,  34  were  strangulated  and  3 
deaths  occurred.  Of  125  femoral  hernias,  10  were  strangulated,  and  no 
deaths  occurred.  Of  82  ventral  hernias  and  114  umbilical,  7  were  stran- 
gulated. They  also  operated  on  12  sliding  hernias,  usually  of  the  sigmoid 
or  cecum,  and  6  hernias  containing  appendix,  ovary  and  tube,  etc.  In  all 
cases  of  direct  hernias  they  transplant  the  cord,  doing  a  Bassini  operation. 

F.  W.  McRae,  of  Atlanta,  Ga.,  since  1902,  has  operated  on  30  cases 
of  hernia,  with  only  one  return,  in  the  case  of  a  double  hernia,  at  about 
the  sixth  month.    The  patient  was  very  poorly  developed  physicalh'. 

J.  Y.  Brown,  of  St.  Louis,  operated  on  350  cases,  with  only  one  return. 

F.  G.  Connell,  Oshkosh,  Wis.,  operated  on  50  cases,  with  no  return, 
but  a  direct  hernia  developed  in  one  case  which  he  ascribes  to  faulty 
technic. 

A  recurrence  took  place  in  two  other  cases,  but  one  of  these  was  com- 
plicated by  an  undescended  testis,  and  the  other  had  been  operated  on  for 
a  recurrence  after  a  Bassini  operation. 

A.  J.  Ochsner,  of  Chicago,  has  informed  me  that  during  the  past  four 
years  he  has  done  all  his  herniotomies  according  to  the  Ferguson  method. 
For  some  time  prior  to  that  he  performed  the  Bassini  on  one  side  and  the 


PLATE  XXXVII. 
Parks'  Autoplastic  Suture. 
I.  Sac  dissected  out.     2.  Suture  applied.     (Courtesy  of  Lea  Bros.  &  Co.) 


RESULTS    FROM    FERGUSON    METHOD  223 

Ferguson  on  the  other  in  cases  of  double  inguinal  hernia,  but  finally  he 
discarded  the  Bassini  operation  entirely. 

Of  710  cases  of  hernia  of  all  varieties,  operated  on  by  Ochsner  in  his 
service  at  the  Augustana  Hospital  for  the  radical  cure  of  oblique  inguinal 
hernia,  all  the  patients  lived.  There  were  few  complications  and  very  few 
recurrences.  Ochsner  had  740  cases  of  non-strangulated  oblique  inguinal 
hernia,  and  33  cases  of  strangulated  hernia.  In  283  cases  of  oblique  in- 
guinal hernia  operated  on  according  to  my  method,  no  deaths  occurred  and 
only  three  recurrences.  These  recurrences  were  probably  due  to  the  pres- 
ence of  a  deficient  conjoined  tendon.  Nevertheless,  there  were  in  this  series 
1.06  per  cent,  of  recurrences. 

In  Ochsner 's  series  there  were  51  cases  of  umbilical  hernia,  in  3  of 
which  strangulation  had  occurred;  81  femoral  hernias,  17  of  which  were 
strangulated;  62  post-operative  ventral  hernias,  and  13  cases  of  hernia  of  the 
linea  alba.  Ochsner  mentioned  only  those  cases  seen  by  him  in  his  service  in 
the  Augustana  Hospital.  Making  a  general  estimate  of  the  total  number 
of  operations  performed  by  him,  it  may  be  said  that  three  or  four  hun- 
dred other  cases  may  be  added  to  this  list,  inasmuch  as  he  has  a  verv  large 
surgical  clinic  at  the  College  of  Physicians  and  Surgeons,  another  at  St. 
Mary's  Hospital,  and  others  elsewhere.  If  we  include  in  this  number  the 
herniotomies  performed  by  E.  H.  Ochsner,  the  number  of  operations  done 
would  be  still  greater.  E.  H.  Ochsner's  results  compare  very  favorably 
with  those  of  his  brother. 

Inasmuch  as  I  am  not  in  possession  of  complete  information  as  to 
the  number  of  patients  operated  on  according  to  my  method  by  other  opera- 
tors than  those  mentioned,  it  is  impossible  to  present  a  complete  report. 
But  the  results  quoted  above  will  serve  for  comparison  with  those  obtained 
by  other  methods. 


PART  II. 

CHAPTER  1. 

OPERATIONS  FOR  INGUINAL  HERNIA. 

In  taking  up  the  various  operations  that  have  been  devised  for  the 
cure  of  hernia,  it  is  not  my  intention  to  make  any  extended  remarks  in  the 
way  of  comment.  I  merely  propose  to  mention  those  procedures  that  can 
be  designated  as  definite  individual  operations,  and  to  describe  briefly  such 
of  the  modifications  of  these  original  procedures  as  have  met  with  the  favor 
of  operators  of  experience.  It  will  be  noted  that  the  list  of  operations  is 
a  long  one,  and  if  I  have  failed  to  mention  any  procedure,  it  is  only  because 
it  was  overlooked  and  not  because  of  any  intention  on  my  part  to  slight 
the  work  done  by  anyone. 

Many  operations  so-called  are  really  merely  modifications,  some 
slight  and  some  more  extensive,  of  older  operative  procedures ;  but  in 
some  instances  the  modifications  possess  the  merit  that  the  original  proced- 
ure lacks.  I  have  not  attempted  to  place  these  operations  in  any  order, 
either  as  to  value  or  precedence,  but  mention  them  as  they  have  occurred 
to  me.  Whenever  possible,  I  have  elucidated  the  text  with  illustrations, 
which  will  be  of  considerable  interest  to  the  reader,  inasmuch  as  they  are  re- 
productions of  the  originals  given  us  by  the  authors. 

MACEWEN'S  OPERATION. 

The  method  employed  by  Macewen  for  the  radical  cure  of  oblique 
inguinal  hernia  aims  at  leaving  the  structures  in  their  normal  position 
after  the  operation,  the  sac  of  the  hernia  being  utilized  to  form  a  boss  at 
the  internal  ring.  The  primary  incision  is  made  directly  over  the  internal 
ring,  commencing  an  inch  or  two  above  the  ring,  and  extending  downward 
over  the  hernia  for  three  or  four  inches.  This  incision  passes  through 
the  two  layers  of  superficial  fascia  and  the  fat  betwefen  them.  The  inguinal 
canal  is  then  opened  by  cutting  through  the  external  ring,  and  separating 
the  fibers  of  the  aponeurosis  of  the  external  oblique,  to  a  point  above  the 
internal  ring.  If  the  sac  can  be  dealt  v/ith  without  making  this  latter  in- 
cision, well  and  good.  It  can  be  dispensed  with  under  such  circumstances. 
Any  rolls  of  fat  that  may  be  found  around  the  cord  or  along  the  sac  must 
be  removed. 

The  sac  itself  is  now  dissected  out  carefully  and  is  separated  at  its 
neck  from  the  transversalis  fascia,  the  finger  being  used,  for  the  space  of 
about  an  inch  around  the  internal  ring.     If  there  is  any  question  in  the 


226  OPERATIONS    FOR    INGUINAL    HERNIA 

mind  of  the  operator  as  to  the  existence  of  omental  adhesions,  the  sac  is 
opened  and  inspected.  If  the  sac  is  very  large  and  redundant,  a  portion 
of  its  fundus  is  cut  off.  The  sac  is  now  ready  to  be  folded  on  itself  into  a 
boss.  j\Iedium-sized  chromic  catgut  is  fastened  firmly  into  the  fundus  or 
cut  end  of  the  sac.  as  the  case  may  be,  and  with  a  non-cutting  needle  it  is 
passed  through  the  sac  from  fundus  to  neck  in  a  zigzag  fashion,  the  last 
two  stitches  being  taken  on  a  level  with  the  peritoneal  cavity.  The  finger 
is  then  passed  between  the  transversalis  fascia  and  the  peritoneum  under 
the  upper  border  of  the  internal  ring.  Using  the  finger  as  a  guide,  the 
needle  is  passed  in,  is  made  to  pierce  the  transversalis  fascia,  and  the 
transversalis,  internal  and  external  oblique  muscles,  emerging  subcuta- 
neously  at  the  upper  angle  of  the  wound.  Traction  being  made  on  this 
puckering  or  folding  stitch,  the  sac  is  drawn  upward  and  inward  so  as  to 
fold  on  itself  until  it  comes  to  occupy  the  internal  aspect  of  the  internal 
ring.     The  puckering  stitch  is  secured  subcutaneously  and  tied. 

The  next  step  in  the  operation  is  to  overlap  Poupart's  ligament  onto 
the  conjoined  tendon,  thus  restoring  the  natural  valve-like  condition  of 
these  structures,  leaving  the  cord  in  its  bed. 

Macewen  uses  a  special  needle  for  this  purpose,  but  any  needle  with- 
out a  cutting  edge  will  do.  The  needle  is  passed  through  the  conjoined 
tendon  from  without  inward  immediately  above  the  pubic  bone,  and  then 
is  passed  along  the  tendon  posteriorly,  emerging  just  short  of  gripping  the 
deep  epigastric  vessels  from  within  outward  (Fig.  25).  The  free  ends  of 
this  stitch  (very  stout  chromic  catgut)  are  then  passed  through  Poupart's 
ligament,  one  opposite  the  internal  ring,  and  the  other  an  inch  and  a  half 
or  so  below  it,  pulled  tightly  and  tied.  In  this  way  Poupart's  ligament  is 
made  to  overlap  onto  the  conjoined  tendon.  If  there  is  any  tendency 
of  the  sac  to  protrude,  one  or  two  stitches  of  finer  catgut  are  inserted  in 
the  same  manner,  gripping  the  lower  border  of  the  internal  oblique  muscle 
and  Poupart's  ligament  respectively;  or,  again,  if  there  seems  to  l3e  more 
space  below  the  great  mattress  suture  than  appears  proper,  one  or  two 
stitches   are   inserted   there   for   additional  security. 

The  aponeurosis  of  the  external  oblique  muscle  is  dealt  wdth  either  by 
a  simple  continuous  suture,  or  by  overlapping  the  cut  edges.  In  chronic 
cases  overlapping  is  the  preferable  procedure,  as  revived  by  Andrews  in 
bis  imbrication  method. 

The  edges  of  the  skin  wound  are  brought  together  either  by  con- 
tinuous or  interrupted  sutures.  The  wound  is  dressed  and  the  patient  is 
kept  in  bed  for  from  four  to  six  weeks.  The  dressing  is  changed  as  often 
as  is  required. 

Macewen's  operation  v^as  the  first  rational  procedure  presented  to  the 
profession  for  the  radical  cure  of  oblique  inguinal  hernia.  It  served  me 
very  usefully,  because  from  it  I  worked  out  my  present  method,  the  typic 
operation  for  the  cure  of  obhque  inguinal  hernia.  While  I  have  discarded 
utilizing  the  sac  as  a  boss  in  the  vast  majority  of  cases,  I  still  occasionally 
make  use  of  it  after  the  method  of  Macewen.  I  have  performed  the  Mac- 
ewen operation  fifty-two  times     without  a  recurrence,  so  far  as  I  know. 


PLATE  XXX\7II. 

Bassini's  Operation  for  Inguinal  Hernia  with  Imbrication  of  Structures,  as 
recommended  bv  E.   W'vllvs  Andrews. 


OPERATIOXS  FOR  IXGUIXAL  HERXIA  229 

There  is  very  little  danger  of  the  sac  dying-  and  coming  away  as  a  slough, 
if  care  is  taken  not  to  injure  its  neck  and  not  to  pass  a  ligature  around  it 
at  the  internal  ring,  as  has  been  done  by  some  operators. 

Macewen  recognized  that  two  conditions  had  to  be  rectified:  (a)  The 
anatomical  infundibuliform  process  at  the  internal  ring,  and  (b)  the  ac- 
quired funnel-shaped  depression  described  by  Sir  Astley  Cooper.  Macewen 
aimed  to  do  this  by  using  the  sac  as  a  plug  or  boss. 

It  was  my  privilege  some  years  ago  (1889)  to  examine  an  anatomical 
preparation  in  the  possession  of  Sir  AVilliam  Macewen  which  had  been 
removed  from  a  patient  whom  he  had  cured  by  his  operation.  The  man 
had  done  heavy  work  for  years  afterward,  although  he  did  not  wear  a 
truss.  The  cause  of  his  death  was  aortic  aneurism.  The  specimen  showed 
the  inguinal  canal  closed  tightly,  and  at  the  abdominal  aspect  of  the  in- 
ternal ring  the  sac  was  folded  on  itself  forming  a  cushion  which  abso- 
lutely prevented  the  possibility  of  a  recurrence  of  the  hernia.  Alacewen 
told  me  that  the  hernia  had  been  one  of  long  standing,  and  that  the  sac  was 
a.  very  large  one,  composed  principally  of  mature  fibrous  tissue. 

If  the  rupture  be  a  recent  one,  and  if  the  sac  is  composed  of  deli- 
cate elastic  peritoneum,  then  I  can  readily  understand  the  correctness  of 
Bassini's  observation  that  at  an  autopsy  made  ninety-five  days  after  an 
operation  somewhat  like  Alacewen's,  no  trace  of  the  tampon  could  be  dif- 
ferentiated. That  the  tampon  "must  of  necessity  leave  a  hard,  painful 
svv^elling,  slow  to  disappear",  as  stated  by  Marcy,  of  Boston,  has  not  been 
my  observation  in  a  single  instance. 

BASSINI'S  OPERATION. 

The  Bassini  operation  is  very  dissimilar  to  that  of  ]\Iacewen.  Bassini 
does  not  make  any  use  of  the  sac,  merely  passing  a  ligature  around  the 
neck  of  the  sac  and  cutting  it  off.  The  cord  is  raised  completely  out  of 
its  bed  and  is  carried  to  the  upper  and  outer  angle  of  the  wound,  which 
displaces  it  about  half  an  inch.  Then  the  lower  border  of  the  internal 
oblique  muscle  and  the  conjoined  tendon  are  sutured  beneath  the  cord  to 
the  inner  aspect  of  Poupart's  ligament,  care  being  taken  to  fit  the  cord 
at  the  internal  ring  as  closely  as  is  compatible  with  its  safety  (Fig.  26). 

A  number  of  operators  have  found  it  necessary  to  place  one  or  two 
stitches  above  the  cord  between  the  internal  oblique  muscle  and  Poupart's 
ligament,  experience  having  shown  them  that  about  six  per  cent,  of  the 
recurrences  take  place  at  this  angle. 

The  aponeurosis  of  the  external  oblique  muscle  is  then  sutured  care- 
fully over  the  cord  and  the  superficial  skin  v/oimd  is  closed  in  the  usual 
manner. 

On  account  of  the  large  number  of  rela.pses  and  complications  occur- 
ring after  this  operation,  seen  by  me  and  also  by  others,  I  set  myself  the 
task  of  devising  an  improvement.  The  returns  of  the  hernia  after  Bas- 
sini's operation,  and  after  modifications  of  i)t.  in  my  experience  were  be- 
tween six  and  seven  per  cent,  in  a  series  of  165  cases.  (Eleven  recur- 
rences, all  at  the  upper  angle  of  the  woiuid.) 


230  OPERATIONS    FUR    INGUINAL     HERNIA 

KOCHEE'S  OPERATION. 

Kocher  makes  use  of  the  sac  subcataiieously  on  the  outside  of  the 
aponeurosis  of  the  external  obhque  muscle  instead  of  subperitoneally,  as 
is  the  case  in  Macewen's  operation.  The  external  ring  and  the  aponeurosis 
of  the  external  oblique  muscle  in  front  of  the  inguinal  canal  are  left  intact 
by  Kocher.  A  small  transverse  incision  is  made  opposite  the  internal  ring, 
passing  through  the  aponeurosis  of  the  external  oblique  muscle.  The  sac 
is  dissected  out  very  carefully  and  freed  up  to  its  neck,  and  after  having 
made  sure  that  its  contents  have  been  returned  to  the  abdominal  cavity, 
the  sac  is  dragged  through  the  small  slit  (Fig.  27),  twisted  vigorously 
on  itself,  and  sutured  in  front  of  the  inguinal  canal  in  such  a  manner  as  to 
press  on  it. 

In  a  second  operation  devised  by  Kocher,  which  is  really  a  modifica- 
tion of  the  first,  he  ablates  the  sac  after  fastening  it  to  the  external  aspect 
of  the  aponeurosis  of  the  external  oblique  muscle  (Fig.  28).  This  modi- 
lication  was  devised  because  of  the  sloughing  of  the  sac  in  the  old  opera- 
tion. Kocher  urges  the  use  of  his  operation  (i)  on  account  of  its  safety  m 
old  subjects;  (2)  suppuration  will  destroy  Bassini's  results,  but  not  his. 
Among  126  patients  operated  on  by  this  method,  there  were  only  foiu'  re- 
lapses, about  3  per  cent.,  while  the  former  procedure  was  followed  by  a 
relapse  in  about  20  per  cent,  of  the  cases. 

HALSTED'S  OPERATION. 

In  1893  W.  S.  Halsted  devised  an  operation  for  the  radical  cure  of 
hernia.  Experience  showed,  however,  that  the  operation  was  not  as  satis- 
factory as  Halsted  at  first  thought  it  would  be.  and  therefore  a  new  opera- 
tion has  been  substituted  for  it.  The  cord  is  no  longer  raised  from  its  bed 
and  transplanted,  nor  are  the  abdominal  muscles  incised  above  the  in- 
ternal ring.  This  modification,  which  is  very  similar  to  my  operation,  was 
not  published  until  three  years  after  I  produced  my  method. 

The  steps  of  this  operation  are  so  well  shown  in  the  illustrations  made 
by  Brodel,  and  reproduced  by  Miss  Cleaveland,  that  a  description  is  almost 
superfluous  for  those  who  consult  the  plates.  The  aponeurosis  of  the  ex- 
ternal oblique  muscle  is  divided  and  the  two  flaps  are  reflected  as  in  the 
Bassini-Halsted  operation.  The  cremaster  muscle  and  fascia  are  split, 
not  directly  over  the  center  of  the  cord,  but  a  little  above  it.  The  internal 
oblique  muscle  is  dissected  free  as  much  as  is  possible.  A  little  artefaction 
is  often  necessary.  If  the  muscle  cannot  be  drawn  down  to  Poupart's  liga- 
ment, without  exerting  too  much  tension  thereon,  it  is  advisable  to  make 
one  or  two  incisions  in  the  anterior  sheath  of  the  rectus  muscle  under  the 
aponeurosis  of  the  external  oblique.  This  sheath  serving,  in  part,  as  the 
aponeurosis  of  the  internal  oblique  muscle,  it  can  be  seen  quite  readily 
that  incisions  into  it,  if  properly  made,  will  be  of  service.  It  is  advisable, 
however,  to  postpone  the  making  of  these  incisions  until  the  suturing  of 
the  internal  oblique  muscle  to  Poupart's  ligament  is  begun.  Then  the  de- 
gree of  tension  present  can  be  gauged,  and  the  number,  length  and  pre- 
cise position  of  the  incisions  determined.     A  second  reason  for  postponing 


PLATE  XXXIX. 
McArthur's  Autoplastic   Suture  used  in  Bassini's   Operation. 


OPERATIONS    FOR    INGUINAL    HERNIA  233 

these  relaxation  incisions,  as  they  are  termed,  is  that  sometimes  this  por- 
tion of  the  rectus  sheath  is  used  for  the  purpose  of  closing  the  lower  part 
of  the  inguinal  canal  (Fig.  33). 

When  the  veins  are  very  large,  Halsted  states  they  should  be  excised, 
but  with  very  great  care,  so  as  to  avoid  even  the  slightest  extravasation  of 
blood  into  the  tissues.  The  vas  deferens  should  not  be  raised  from  its  bed 
or  even  handled  lest  thrombosis  of  its  veins  occur. 

The  veins  should  be  ligated  as  high  up  in  the  abdomen  as  possible. 
They  are  pulled  down  quite  firmly  just  before  the  ligature  (  in  a  needle 
with  a  blunt  end)  is  passed  between  them.  In  order  to  obviate  slipping, 
two  ligatures  of  fine  silk  are  applied,  one  to  the  abdominal  stump  and  the 
other  to  the  proximal  stump  of  the  veins.  The  farther  from  the  testicle 
these  veins  are  divided,  the  better;  provided,  of  course,  that  the  stump 
is  external  to  the  external  abdominal  ring. 

Ligation  of  the  sac  by  transfixion  or  by  purse-string  suture  at  the 
highest  possible  point.  Both  ends  of  this  suture,  after  tying,  are  threaded 
on  long  curved  needles,  then  carried  far  out  under  the  internal  oblique 
muscle  from  behind  forward,  and,  passing  through  muscle,  about  5  mm. 
apart,  are  tied.  The  idea  was  suggested  to  the  author  by  Kocher's  opera- 
tion, the  principle  being  essentially  the  same. 

The  lower  flap  of  the  cremaster  muscle  and  its  fascia  is  drawn  up 
under  the  mobilized  internal  oblique  muscle  and  held  in  this  position  by 
very  fine  silk  stitches,  which,  having  engaged  firmly  a  few  bundles  of  the 
cremaster,  perforate  the  internal  oblique,  preferably  where  it  is  becoming 
aponeurotic,  and  are  tied  on  the  external  surface  of  the  latter  (Fig.  29). 

The  internal  oblique  muscle,  mobilized,  and  possibly  further  released 
by  incising  the  anterior  sheath  of  the  rectus  muscle,  is  stitched  (the  con- 
joined tendon  also)  to  Poupart's  ligament  in  the  Bassini-Halsted  man- 
ner (Fig.  30).  Catgut  is  usually  employed  for  this  suture.  The  aponeu- 
rosis of  the  external  oblique  muscle  is  overlapped,  as  in  Andrew's  method 
(Figs.  31  and  32). 

The  skin  is  closed  with  a  buried  continuous  silver  suture  and  the 
incision  covered  with  five  or  six  layers  of  silver  foil.  It  is  unnecessary  to 
dress  or  examine  a  wound  closed  in  this  manner  for  two  weeks,  when  the 
wire  may  be  withdrawn.  Patients  are  kept  in  bed  from  eighteen  to  twenty- 
one  days. 

Halsted  says,  "We  hope  to  be  able  to  publish  very  soon  the  results 
of  the  first  1,000  operations  performed  for  the  cure  of  inguinal  hernia  at 
the  Johns  Hopkins  Hospital.  Certainly  more  than  two-thirds  of  the  opera- 
tions have  been  performed  by  my  associates,  Drs.  Finney,  Bloodgood, 
Cushing,  Mitchell  and  Follis,  for  we  are  all  much  interested  in  the  sub- 
ject. Each  operator  has  been  at  perfect  liberty  and  is  encouraged  to  per- 
form the  operation  according  to  his  best  judgment.  This  fortunately 
furnished  a  little  variety,  but  of  late  the  operation  has,  in  almost  every  de- 
tail, been  performed  just  as  the  writer  has  described  it." 


234  OPERATIONS  FOR  INGUINAL  HERNIA 

FOWLER'S  OPERATION. 

The  late  George  Ryerson  Fowler,  of  Brooklyn,  N.  Y.,  described  an 
operation  for  the  radical  cure  of  inguinal  hernia  which  he  termed  an  intra- 
peritoneal transplacement  of  the  spermatic  cord  with  typical  obliteration  of 
the  internal  ring-  and  the  inguinal  canal.  In  this  operation  the  skin  incis- 
ion is  curved  and  follows  the  course  of  Poupart's  ligament.  The  sac  and 
cord  are  exposed  in  the  usual  way,  the  sac  is  cut  away,  and  the  cord  is 
raised  from  its  bed.  The  deep  epigastric  vessels  are  tied  twice,  and  then 
severed  between  the  ligatures.  The  posterior  wall  of  the  canal  is  opened 
freely,  the  cord  is  transplanted  within  the  abdominal  cavity,  and  the  wound 
is  then  closed. 

The  patient  is  placed  in  the  Trendelenburg  position,  in  order  that  the 
intestines  may  not  embarrass  the  operator,  subsequent  to  the  opening 
and  emptying  of  the  hernial  sac.  The  incision  commences  at  the  spine  of 
the  pubis,  is  carried  parallel  with  the  os  pubis  for  about  an  inch,  and  then 
curved  obliquely  outward  and  upward  on  the  line  which  marks  the  gen- 
eral direction  of  Poupart's  ligament,_  until  a  point  is  reached  corresponding 
to  the  level  of  the  internal  ring. 

Skin,  fat  and  fascia  to  the  aponeurosis  of  the  external  oblique  are  in- 
cluded in  the  incision.  The  flap  thus  marked  out  is  reflected  when  the 
entire  region  involved  in  inguinal  hernia,  including  the  inguinal  or  sper- 
matic canal,  as  well  as  the  site  of  Plesselbach's  triangle,  is  exposed  to  view. 
The  a:nterior  wall  of  the  canal  is  now  split  up  to  the  site  of  the  internal 
ring. 

The  cord  and  sac  are  first  isolated  together,  the  isolation  commencing 
at  the  pubic  bone,  where  the  cord  is  usually  easily  identified  and  separated, 
these  structures  are  now  separated  from  each  other,  each  being  traced  to 
the  internal  ring  and  thoroughly  isolated  froin  all  structures  in  the  neigh- 
borhood. The  hernial  sac  is  now  opened,  its  contents  reduced,  if  reduc- 
tion has  not  already  occurred,  and  the  sac  cut  away  to  the  level  of  the 
muscular  layer  of  the  abdominal  wall.  Its  incised  edges  are  grasped 
by  forceps  to  prevent  them  from  slipping  away.  The  cord  being  held  out 
of  the  way,  the  place  of  crossing  the  deep  epigastric  artery  on  the  trans- 
versalis  fascia  is  sought,  and  both  the  artery  and  vein  are  isolated  and 
ligated  in  two  places  and  divided  between  the  ligatures. 

The  index  finger  is  now  introduced  into  the  peritoneal  cavity  through 
the  neck  of  the  sac  and  the  posterior  wall  of  the  canal,  as  well  as  the 
site  of  Hesselbach's  triangle,  lifted  up  on  the  palmar  surface  of  the  finger. 
With  the  latter  as  a  guide,  the  entire  intervening  structures  are  divided, 
including,  from  without  mward,  the-  transversalis  fascia,  subperitoneal 
connective  tissue,  and  the  peritoneum  (Fig.  34).  The  spermatic  cord  is 
now  placed  in  the  peritoneal  cavity ;  the  gap  in  the  incised  posterior  wall  in 
the  inguinal  canal  is  held  apart  by  grasping  the  incised  peritoneal  edges 
with  forceps.  In  those  instances  in  which  the  internal  ring  is  greatly 
enlarged  in  all  directions  and  a  large  neck  to  the  hernial  sac  exists,  a  slit 
may  be  made  in  the  edge  of  the  latter  toward  Poupart's  ligament,  in  order 
to  lead  the  cord  easily  into  the  peritoneal  cavity.     The  edges  of  the  open- 


PLATE  XL. 
McxA-rthur's  Autoplastic  Suture  used  in  Bassini's  Operation. 


OPERATIOXS    FOR    IXGUIXAL    HERI.     \.  '  237 

ing  are  now  drawn  forward  so  that  a  broad  approximation  of  their  serous 
surfaces  is  obtained.  While  held  in  this  position,  through-and-through 
sutures  are  passed  from  side  to  side  (Fig.  35).  By  this  maneuver  any  ex- 
isting relaxed  condition  of  this  portion  of  the  transversalis  fascia  is  cor- 
rected. The  suture  is  first  passed  above  the  site  of  the  internal  ring,  and 
includes  the  transversalis  fascia  which  is  drawn  downward  and  forward 
for  that  purpose.  This  serves  to  cover  the  point  where  the  cord  passes 
into  the  peritoneal  cavity  at  the  site  of  the  internal  ring,  thereby  obliter- 
ating the  latter,  the  cord  itself  filling  the  small  opening  in  the  peritoneum. 
The  position  of  the  cord  on  the  peritoneal  surface  of  the  abdominal  wall 
is  such  as  to  act  as  a  "shunt"  carrying  any  intestine  in  the  neighborhood 
away  from  rather  than  toward  the  original  weak  point. 

The  suturing  is  continued  until  the  lower  angle  of  the  gap  in  the 
posterior  wall  of  the  original  inguinal  canal  is  almost  reached.  This  angle 
should  be  made  low  enough  to  compel  the  cord  to  curve  slightly  upward 
and  forward  as  it  leaves  its  place  of  exit  from  the  peritoneal  cavity  at  the 
newly  formed  external  ring.  The  cord  should  rest  easily  in  the  angle, 
and  the  suturing  stop  short  of  constricting  it  therein. 

The  inguinal  canal,  including  the  gap  in  the  aponeurosis  of  the  ex- 
ternal oblique  which  represents  the  external  ring,  and  the  skin  wound  are 
now  to  be  closed.  The  canal  sutures  include  the  conjoined  tendon  and  the 
aponeurosis  of  the  external  oblique  on  the  inner  margin,  and  Poupart's 
ligament  on  the  outer.  The  two  sutures  should  include  the  outer  edge 
of  the  pyramidalis,  if  this  is  present,  and  if  not,  the  rectus  muscle.  The 
effect  of  this  is  to  displace  a  portion  of  the  muscular  tissue  to  a  situation  to 
guard  the  point  of  exit  of  the  spermatic  cord  (Fig.  36).  A  continuous 
suture  is  now  applied  in  order  to  secure  a  more  accurate  coaptation  of  the 
margins  of  the  aponeurosis  of  the  external  oblique  muscle,  the  turns  of 
suture  passing  in  the  space  between  the  interrupted  sutures.  The  skin 
wound  is  closed  by  a  subcuticular  or  other  appropriate  suture,  and  proper 
sterile  dressings  are  applied. 

I  have  performed  this  operation,  or  a  modification  of  it,  forty-five 
times,  usually  in  cases  where  the  hernia  was  complicated  by  a  non-de- 
scended testis.  The  operation  gives  the  vas  deferens  a  shorter  route  be- 
tween the  testes  and  the  base  of  the  bladder.  I  have  also  used  the  method 
in  the  treatment  of  both  direct  and  indirect  inguinal  hernias,  where  the 
hernia  protruded  considerably  and  where  there  was  more  or  less  bulging 
of  the  posterior  wall  of  the  canal  and  the  deep  epigastric  vessels.  In  cer- 
tain conditions  it  is  not  necessary  to  cut  the  peritoneum,  although  the  deep 
epigastric  vessels  are  severed. 

LANPHEAR'S  OPERATION. 

Emory  Lanphear,  of  St.  Louis,  in  operating  for  inguinal  hernia,  forms 
a  flap  and  turn  it  down  so  as  to  expose  the  hernial  sac  and  the  inguinal 
canal.  The  sac  is  then  isolated,  opened,  and  its  contents  reduced.  The 
opening  in  the  abdomen  is  closed  temporarily  with  a  gauze  pad,  and  the 
cord  and  testes  are  elevated  out  of  their     new  position  and     wrapped  in 


238  OPERATIONS    FOR    INGUINAL    HERNIA 

iodoform  gauze.  From  the  hernial  sac  an  artificial  vaginal  tunic  is  made 
into  which  the  cord  and  testes  are  passed,  the  tunic  being  sutured  in  such 
a  manner  that  not  too  much  pressure  is  made  on  the  cord.  This  mass 
of  tissue  is  pushed  into  the  abdominal  cavity  and  anchored  by  catgut  su- 
tures. Next,  he  closes  the  incision  in  the  peritoneum  and  then  the  open- 
ing in  the  scrotum.  The  abdominal  wall  is  sutured  in  layers  so  as  to 
obliterate  the  inguinal  canal. 

The  objection  to  the  operation  is  that  in  case  there  occurs  suppura- 
tion of  the  testes  or  an  epididymitis,  it  would  be  necessary  to  open  the 
abdomen  in  order  to  give  operative  relief. 

GIRAKD'S  OPERATION. 

Girard  splits  the  skin  and  the  aponeurosis  of  the  external  oblique 
muscle  somewhat  after  the  fashion  of  Bassini's  operation,  but  he  pre- 
serves a  strip  of  the  muscle,  about  the  width  of  a  finger,  at  its  attachment 
to  Poupart's  ligament.  A  purse-string  suture  being  passed  through  the 
neck  of  the  sac,  the  sac,  of  course,  having  been  cut  off,  it  is  dropped  back 
into  the  abdominal  cavity.  The  internal  oblique  and  transversalis  muscles 
are  sutured  to  the  underside  of  Poupart's  ligament,  a  running  catgut  stitch 
being  used.  The  external  oblique  muscle  is  then  likewise  sutured  to  the 
underside  of  Poupart's  ligament  and  then  the  strip  of  muscle  is  passed 
in  under  the  ligament  and  sutured  to  the  aponeurosis  of  the  external 
oblique  muscle,  so  that  for  a  certain  distance  this  aponeurosis  is  doubled, 
an  opening  is  left  at  the  lower  angle  of  the  exit  of  the  cord.  The  skin  is 
closed  with  a  continuous  suture. 

PARK'S  ATJTO-SUTTJRE  (SAC)  OPERATION. 

Roswell  Park  recently  devised  a  new  method  of  utilizing  the  sac. 
The  sac  having  been  exposed  and  isolated,  is  emptied  of  its  contents  and 
freed  of  all  superficial  fat.  It  is  separated  from^  the  cord  and  made  to 
appear  as  a  distinct  separate  structure  up  to  the  level  of  the  internal  ring. 
The  abdominal  aponeurosis  is  penetrated  with  forceps  at  a  point  opposite 
the  internal  ring,  and  the  forceps  introduced  through  this  opening  is  made 
to  appear  lower  down  in  the  inguinal  canal,  the  sac  is  seized,  and  is  with- 
drawn together  with  the  forceps,  thus  bringing  it  out  at  the  punctured 
point. 

Instead  of  cutting  ofif  the  sac  outside  the  point  where  it  is  fastened. 
Park  utilizes  it  as  a  band  of  suture  material  with  which  a  coarse  strong 
suture  is  made  binding  together  the  lateral  margins  of  the  inguinal  canal 
(Fig.  37).  Of  course,  much  depends  on  the  thickness  and  length  of  the 
sac.  Old  and  large  sacs  are  far  too  cumbersome  for  this  purpose,  and 
short  sacs  cannot  be  made  to  serve  as  sutures  when  twisted  into  a  cord. 
These  difificulties  are  overcome  easily  either  by  reducing  the  sac,  cutting 
out  a  strip  which  can  be  made  to  serve  as  a  suture,  or  by  lengthening 
the  strip  by  division,  so  that  a  suture  five  or  six  inches  long  can  be  ob- 
tained from  a  short  sac. 

The  sac  having  been  prepared,  it  may  be  used  in  one  of  two  or  three 


PLATE  XLI. 
M.  L.  Harris'  aluminum  bronze  wire  suture  used  in  Ferguson's  operation. 


OPERATIONS    FOR    INGUINAL    HERNIA  24I 

ways.  A  very  large  needle  may  be  threaded  with  the  suture  or  a  Cleveland 
ligature  carrier  may  be  used,  passing  it  through  the  tissues  on  either  side  as 
if  it  were  an  ordinary  needle,  then  grasping  the  end  of  the  sac  and  pulling 
it  back  through  the  openings  thus  made  as  the  instrument  is  withdrawn. 
Sometimes  Park  passes  into  the  end  of  the  sac  a  silk  suture,  threading  it 
into  a  larger  needle,  and  making  it  serve  as  a  means  of  traction,  the  pro- 
cedure varying  a  little  with  the  density  and  strength  of  the  sac  wall. 

In  certain  cases  the  portion  of  sac  used  may  be  divided  into  halves, 
making  two  tapes  which  can  be  used  in  the  form  of  a  shoelace  suture  of 
the  pillars  of  the  ring  by  either  of  the  expedients  mentioned.  The  ends 
are  drawn  down  at  the  lower  end  of  the  ring,  where  they  are  tied  and  fas- 
tened with  a  suture. 

The  method  is  not  applicable  to  all  cases,  nor  is  it  likely  to  displace 
other  procedures.  It  should  not  be  employed  unless  the  operation  can  be 
performed  deliberately  and  only  in  the  absence  of  infection. 

WULLSTEIN'S  OPERATION. 

Quite  recently  Wullstein  (Centralbl.  f.  Chirurgie,  No.  38,  1906)  pro- 
posed a  new  method  for  the  cure  of  inguinal  hernia.  The  incision  starts 
at  the  pubic  spine  and  makes  a  bow-shaped  curve  upward  and  outward, 
running  from  one  to  two  finger-breadths  above  Poupart's  ligament  and 
extending  to  the  neighborhood  of  the  internal  inguinal  ring.  The  skiri 
liap  is  reflected  downward  to  Poupart's  ligament.  The  sac  is  isolated  in 
the  usual  way  and  the  aponeurosis  of  the  external  oblique  muscle  is  split 
as  far  as  the  internal  ring.  The  sac  is  then  tied  off  at  the  neck  and  cut 
away.  The  cremaster  fibers  are  separated  from  the  cord,  but  are  allowed 
to  remain  in  connection  with  the  external  oblique  muscle  and  Poupart's 
ligament.  The  transversalis  fascia  is  split  almost  to  the  internal  pillar 
of  the  external  ring,  and  the  cord  is  dislocated  backward  so  as  to  lie  be- 
tween the  transversalis  fascia  and  the  preperitoneal  fat.  The  external 
oblique,  internal  oblique  and  transversalis  m.uscles  and  the  transversalis 
fascia  are  united  to  the  posterior  surface  of  Poupart's  ligament  by  inter- 
rupted sutures  as  far  as  the  external  inguinal  ring.  In  order  to  restore  nor- 
mal tension,  -the  sutures  are  placed  a  little  nearer  the  middle  line  in  Poupart's 
ligament  than  in  the  abdominal  wall. 

A  plastic  flap  is  then  constructed.  The  skin  is  pulled  inward  in  order 
to  expose  the  rectus  muscle.  The  outer  two-thirds  of  the  anterior  rectus 
sheath  is  cut  transversely  across  immediately  above  the  level  of  the 
symphysis,  thus  exposing  both  the  rectus  and  the  pyramidalis  fibers.  The 
cut  is  continued  upward  and  outward  until  it  ends  opposite  the  pubic  spine, 
hut  about  four  centimeters  above  it.  This  gives  a  tongue-shaped  flap 
which  is  freed  from  the  muscle  and  reflected  outward  to  the  outer  edge 
of  the  rectus  muscle.  The  fibers  forming  the  inner  pillar  of  the  external 
ring  prevent  a  complete  reflection  of  the  flap,  and  these  fibers  are  now  cut 
across  close  to  Poupart's  ligament.  The  remainder  of  the  hernial  opening 
is  closed  by  suturing  the  abdominal  muscles  to  Poupart's  ligament. 

The  purpose  of  the  flap  is  to  be  placed  behind  the  rectus  muscle.     The 


242 


OPERATIONS    FOR    INGUINAL    HERNIA 


three  sutures  used  to  transpose  the  flap  also  serve  to  fix  and  carry  the 
cord  into  its  new  bed.  The  sutures  are  of  the  mattress  type,  the  low- 
est being  placed  horizontally,  and  the  upper  two  vertically.  They  all  pierce 
the  rectus  muscle  and  enter  the  fascial  flap  some  distance  away  from  its 
free  edge.  When  the  sutures  are  tied  the  aponeurotic  flap  is  pulled  be- 
hind the  rectus  muscle,  the  cord  assuming  a  course  running  well  behind 
this  muscle,  and  then  curving  outward  and  downward  to  reach  the  scro- 
tum. It  is  surrounded  on  all  sides,  except  below,  by  rectus  muscle,  which 
is  also  sewn  to  Poupart's  ligament.  The  gap  in  the  rectus  sheath  is  re- 
paired simply  by  stitching  the  two  edges  together.  The  cord  thus  is  made 
to  lie  in  a  new  canal  behind  the  rectus  muscle,  so  that  straining  or  cough- 
ing merely  presses  aponeurotic  flap  to  muscle. 

Wullstein  has   used  this   method  with  perfect   results   in    19   cases   of 
direct  and  indirect,  reducible  and  irreducible  hernia. 

NICHOLL'S  OPERATION. 

Nichoirs  operation  (Annals  of  Surgery,  Jan.,  1906)  is  really  a  modi- 
fication of  other  operations.  The  hernial  sac  is  treated  as  before,  but  it  is 
lodged  over  the  internal  aspect  of  the  internal  inguinal  ring  as  a  pad,  resting 
between  the  parietal  peritoneum  on  the  one  hand  and  the  fascia  transversaHs 
on  the  other.  With  blunt  retractors  the  round  ligament,  or  the  cord,  is 
pulled  upward,  and  Poupart's  ligament  downward.  An  incision  is  carried 
along  the  superior  aspect  of  the  pubic  ramus.  Its  limits  are  the  pubic 
spine  and  the  femoral  sheath.  This  divides  the  iliac  fascia,  the  origin  of 
the  pectineus  and  the  periosteum.  "Slightly  detach  both  margins  of  the 
periosteal  wound,  and  drill  the  bone  near  its  upper  margin,  as  before,  some- 
where between  the  pubic  spine  and  the  femoral  sheath,  the  position  of  the 
holes  varying  with  the  shape  and  size  of  the  hernial  aperture.  Pass  a  stout 
absorbable  ligature  in  the  form,  of  a  large  mattress  suture  through  the 
internal  pillar  of  the  hernial  aperture;  pass  the  ends  of  the  suture  out 
through  the  holes  drilled  in  the  bone  and  either  in  front  of  or  behind  the 
spermatic  cord  as  seems  best  to  secure  firm  closure  of  the  canal  without 
undue  compression  of  the  cord.  Tie  the  ends  of  the  two  loops  of  the 
ligature  separately.  The  tightening  of  the  knots  brings  the  internal  pillar 
down  into  the  periosteal  incision  and  lodges  it  firmly  against  the  bone. 
The  knots  may  be  placed  either  above  or  below  Poupart's  ligament." 

The  operation  is  completed  by  lifting  Poupart's  ligament  to  the  an- 
terior surface  of  the  internal  pillar  and  fixing  it  there  by  interrupted  sutures 
of  stout  catgut  or  other  absorbable  material  which  should  penetrate,  at 
least,  the  external  and  internal  oblique  muscles. 

BECK'S  OPERATION. 

Carl  Beck,  of  New  York,  makes  an  incision  down  to  the  internal 
surface  of  Poupart's  ligament  and  alongside  the  rectus  muscle.  The  lower 
third  of  this  muscle  is  exposed  down  to  the  shelf  of  Poupart's  ligament. 
The  sac  is  isolated,  ligated  and  cut  off  within  the  internal  ring.  The  cord 
is  held  away,  and  the  divided  aponeuroses  are  dissected  back. 


PLATE  XLII. 
Davison's  Removable  Silkworm   Gut   Suture. 


OPERATIONS  FOR  INGUINAL  HERNIA  245 

An  oblique  incision  is  made  which  divides  the  lateral  fibres  of  the  rec- 
t'ds  transversely,  somewhat  below  the  lower  third  of  the  muscle  and  for 
about  one-third  of  its  width.  The  incised  fibres  are  cut  from  the  remaind- 
er of  the  mus.cle  so  that  when  the  upper  portion  is  turned  downward 
it  will  reach  Poupart's  ligament.  The  muscular  flap  is  then  sutured  on 
one  side  to  the  conjoined  tendon  and  on  the  other  side  to  Poupart's  liga- 
ment. Formalin  catgut  is  employed  for  this  purpose.  The  sutures  are 
tied  after  the  cord  has  been  placed  on  the  transplanted  muscle  flap.  The 
gap  caused  by  transplanting  this  flap  is  closed  by  suturing  the  outer  margin 
of  the  rectus  to  the  broad  abdominal  muscles.  The  divided  aponeuroses  are 
sutured  above  the  cord  by  a  continuous  suture. 

In  my  opinion,  the  severing  of  the  fibers  of  the  rectus  muscle  is  un- 
called for  in  an  operation  for  the  cure  of  hernia.  Without  doubt,  the 
transplanted  flap  strengthens  the  inguinal  region  considerably,  but  why 
resort  to  such  a  complex  procedure  when  a  more  simple  one  will  meet  all 
the  indications? 

STINSON'S  OPERATION. 

J.  C.  Stinson  makes  an  incision  parallel  with  and  one-half  inch  above 
Poupart's  ligament,  extending  from  the  external  ring  to  half  an  inch  above 
the  upper  angle  of  the  dilated  internal  ring.  The  skin,  subcutaneous  tis- 
sues, and  the  aponeurosis  of  the  external  oblique  muscle  are  divided  by 
this  incision.  The  aponeurosis  is  elevated  and  freed  from  the  structures 
beneath  until  the  outer  border  of  the  rectus  muscle  and  the  shelving  edges 
of  Poupart's  ligament  appear  in  the  field. 

The  sac  is  isolated,  opened,  and  its  contents  cleared  out,  all  the  altered 
omentum  being  removed.  All  adhesions  are  separated.  The  sac  is  cut 
off  as  high  as  possible  and  the  cut  edges  of  the  serosa  are  closed  with  con- 
tinuous sutures.  The  rings  and  canal  are  cleared  out.  The  dilated  internal 
ring  is  sutured,  commencing  at  the  upper  angle. 

The  inner  and  outer  borders  of  the  transversalis  fascia  are  brought 
accurately  together  with  continuous  sutures,  leaving  only  sufficient  room  at 
the  lower  angle,  close  to  the  pubic  bone,  for  the  cord.  The  internal  ring  is 
re-enforced  and  the  canal  closed  by  uniting  with  continuous  sutures,  the 
internal  obhque  and  the  transversalis  muscles  and  their  conjoined  tendon 
to  the  shelving  edge  of  Poupart's  ligament,  leaving' only  room  enough 
next  to  the  pubic  bone  for  the  cord.  The  cut  edges  of  the  external  oblique 
and  the  pillars  of  the  external  ring  are  sutured  and  made  to  embrace  the 
cord.  The  skin  is  closed  without  drainage.  Sterilized  gauze  is  held  firmly 
in  place  by  long  strips  of  adhesive  plaster,  then  a  layer  of  cotton  and  over 
all  a  firm  spica  bandage. 

HERRING'S  OPERATION. 

E.  K.  Herring  advocates  the  following  procedure  for  curing  hernias 
in  children:  The  operation  is  said  to  be  a  very  simple  one  and  can  be 
performed  in  a  few  minutes.  The  sac  is  cut  down  on  and  into  in  the  usual 
manner,  and  having  dealt  with  its  contents  it  is  pulled  down,  that  is,  out 


246  .  OPERATIONS    FOR    INGUINAL    BERNIA 

from  the  abdomen,  sufficiently  to  insure  subsequent  retraction.  The  in- 
cision is  extended  in  the  sac  up  to  the  margin  of  the  ring,  and  then  the 
upper  portion  of  the  sac  is  turned  inside  out  through  the  incision,  so  as 
to  expose  the  peritoneal  surface.  Then,  with  a  knife  or-  a  pair  of  scis- 
sors, the  peritoneum  is  cut  across  transversely.  The  proximal  cut  edge 
retracts  into  the  abdomen  and  it  should  be  caught  here  and  there  with 
catch  forceps  as  the  peritoneum  is  cut.  These  catch  forceps  are  ar- 
ranged so  as  to  draw  the  cut  edge  of  the  peritoneum  into  a  straight  line, 
and  the  two  edges  are  stitched  together  by  a  catgut  suture.  The  forceps 
are  then  removed,  and  the  tissue  immediately  retracts.  .  The  opening  is 
closed  with  a  subcuticular  or  other  stitch  and  is  then  sealed. 

Nothing  further  is  absolutely  necessary.  When  there  is  a  large  lax 
abdominal  ring,  or  when  the  little  patient  has  a  cough,  it  may  be  advisable 
to  put  one  or  two  stitches  through  the  pillars  as  a  temporary  support.  The 
contents  of  the  inguinal  canal  are  practically  not  disturbed.  The  sac  is 
left  in  the  canal  to  shrivel  up ;  the  cord  has  not  been  touched  nor  pinched ; 
the  testicle  has  not  been  dragged  out  and  exposed;  no  vessels  have  been 
cut,  so  no  ligatures  are  left  behind,  and  the  chances  of  sepsis  are  very 
slight. 

BENJAMIN'S  OPERATION. 

In  1903,  Benjamin  described  an  operation  for  the  radical  cure  of  ob- 
lique inguinal  hernia  which  possessed  several  distinguishing  features.  An  or- 
dinary incision  was  made,  as  in  the  Bassini  operation,  and  then  the  aponeuro- 
sis of  the  external  oblique  muscle  was  slit  up  to  a  pomt  opposite  the  inter- 
nal ring.  The  fibers  of  the  internal  oblicjue  and  the  transversalis  m.uscles 
were  divided  carefully  by  blunt  dissection,  thus  opening  the  inguinal  canal. 
The  aponeurosis  of  the  external  oblique  was  carefully  and  thoroughly 
removed  from  the  internal  oblique.  The  lower  portion  Avas  dissected  down 
to  Poupart's  ligament,  and  the  transversalis  muscle  separated  from  the 
peritoneum. 

The  cord  is  now  raised  and  silkworm  gut  sutures  are  introduced  to  the 
outer  side  of  the  incision,  passing  through  the  skin,  Poupart's  ligament, 
the  internal  oblique  and  the  transversalis  muscles,  on  the  inner  side  of 
which  the  loop  is  made.  The  needle,  re-entering  the  transversalis  and  inter- 
nal oblique  muscles,  passes  through  Poupart's  ligament  and  comes  out 
through  the  skin  to  the  outer  and  lower  side  of  the  cut  near  the  point  of 
entrance.  From  three  to  five  sutures  are  similarly  introduced.  These 
sutures  pull  the  internal  oblique  and  the  transversalis  muscles  below  the 
shelving  edge  of  Poupart's  ligament,  thus  creating  a  firm'  barrier  against 
any  internal   force. 

The  sutures  are  then  tied  over  rolls  of  sterilized  gauze.  The  cord 
then  rests  on  the  internal  oblique,  the  external  oblique  being  closed  over 
the  cord.  Interrupted  figure-of-eight  sutures  aie  introduced,  bringing  the 
external  oblique  muscle  in  apposition  with  Poupart's  ligament.  The}-  also 
approximate  the  skin  and  are  tied  over  a  gauze  roll. 

This  operation,   according   to   Benjamin,  completely   closes  the  breech 


PLATE  XLIII. 

Showing  Deficiency  of   Internal  Oblique  at  Poupart's   Ligament. 
I.     Usual  deficiency.     2.  Normal  for  male.     3.  Normal  for  female. 


OPERATIONS    FOR    INGUINAL    HERNIA  249 

and  makes  a  firm  wall.  There  are  no  sutures  for  the  tissues  to  absorb; 
no  buried,  non-absorbable  sutures  left  to  irritate  the  tissues  and  cause 
further  trouble ;  no  necrosis  from  tight  sutures ;  therefore,  few,  if  any, 
stitch-abscesses.  All  sutures,  after  serving  their  purpose,  are  removed, 
leaving  only  the  natural  supports,  while  the  gauze  rolls  act  as  elastic 
cushions  which  prevent  scars  from  the  sutures. 

SCHWARTZ'S  OPERATION. 

When  Schwartz  first  described  his  method  for  the  radical  treatment 
of  hernia,  he  called  it  hernial  myoplasty.  It  was  applicable  both  to  inguinal 
and  to  femoral  hernias.  The  incision  is  a  vertical  rather  than  an  oblique 
one.  After  having  exposed  the  hernia,  the  sac  is  isolated,  and  having  tied 
it  as  usual  the  sheath  of  the  rectus  muscle  is  opened  by  a  longitudinal 
incision  six  to  eight  centimeters  in  length.  The  aponeurotic  folds  are 
held  back  by  a  fine  Kocher's  forceps.  A  muscular  flap  with  the  pedicle 
below  is  separated,  using  especially  the  channeled  sound ;  the  muscle 
above  is  seized  en  masse  and  tied  with  catgut  and  cut.  The  flap  is  about 
four  to  five  centimeters  long,  after  retraction,  and  about  a  centimeter  to 
a  centimeter  and  a  half  wide.  All  this  can  be  done  without  causing  any 
hemorrhage,  and  generally  without  tying  a  single  ligature. 

Lifting  the  internal  pillar  with  a  Kocher's  forceps,  the  sheath  of  the 
rectus  muscle  is  opened  below  the  pillar  with  a  bistoury  passed  f^at  and 
the  flap  is  looked  for  as  it  is  made  to  pass  through  the  opening  as  low  as 
possible.  The  incision  in  the  sheath  of  the  rectus  muscle  is  closed  with  a 
few  sutures.  When  this  has  been  done,  the  muscular  flap  is  drawn  into  the 
hernial  region  and  sutured  above  to  the  lower  border  of  the  inferior 
oblique  and  transversaHs  muscles,  and  below  to  the  crural  arch.  The 
hernial  pillars  are  sutured  above  it,  and  the  operation  is  completed  as  usual. 
In  this  way  the  inguinal  orifice,  or,  rather,  the  hernial  opening,  and  all 
the  region  surrounding  it,  is  closed  by  a  solid  flap  of  muscle  which  con- 
stitutes a  natural  barrier. 

WOELFLER'S  OPERATION. 

The  principle  of  this  method  is  the  closure  of  the  hernial  opening  by 
suturing  the  internal  oblique  and  transversalic  muscles  to  Poupart's  liga- 
ment. Woelfier  also  removes  the  rectus  muscle  from  its  sheath  and  sutures 
it  to  Poupart's  ligament.  At  one  time  he  made  use  of  a  method  of  trans- 
posing the  cord,  which  did  not,  however,  prove  very  satisfactory.  It 
consisted  in  removing  the  testes  from  the  scrotum  by  severing  the  guberna- 
culum  of  Hunter.  He  then  severed  the  transversaHs  fascia  at  the  outer 
border  of  the  rectus  muscle  and  separated  the  subserous  fascia  from  the 
recti  muscles.  The  testis  is  then  pushed  in  through  this  opening,  anvi  out 
between  the  two  recti  muscles.  It  is  brought  down  in  front  of  these  mus- 
cles and  transferred  to  the  scrotum,  where  it  is  again  sutured  to  the  guber- 
naculum. 

Naturally,  serious  complications  often  followed  this  method  of  trans- 
position, because  the  cord  was  very  likely  to  be  compressed  by  the  con- 


250  OPERATIONS    FOR    INGUINAL    HERNIA 

tracting  recti  muscles  or  the  formation  of  scar  tissue,  and  the  result  was 
atrophy  of  the  testis.  Gangrene  might  also  ensue.  The  method  was  prac- 
tised but  little  b}-  Woelfler  himself,  and  rarely  by  any  other  operator. 

BALL'S  OPERATION. 

Charles  Ball  operates  on  reducible  inguinal  hernia  as  follows :  An 
incision  one  inch  in  length  is  made  over  the  neck  of  the  hernia.  The 
sac  is  exposed  and  opened,  and  the  finger  is  introduced  to  detect  adherent^ 
omentum.  The  sac  is  then  separated.  If  the  hernia  is  congenital  the  sac 
must  be  divided  circumferentially,  leaving  the  lower  portion,  but  peeling 
off  the  upper  portion  from  the  cord.  The  sac  is  cleared  up  to  the  external 
ring  and  is  twisted  with  forceps.  A  curved  needle  threaded  with  stout 
silk  is  carried  up  one  inch  into  the  subperitoneal  space  along  the  guiding 
finger,  and  then  directed  forward  through  the  muscles  and  skin  of  the 
abdominal  wall.  The  other  end  of  the  same  piece  of  silk  is  passed  to  the 
other  side  of  the  twisted  sac  and  brought  out  through  the  abdominal  wall. 
The  ends  are  tied  together  over  a  lead  plate. 

The  sac  now  lies  in  the  inguinal  canal  and  along  with  the  spermatic 
cord  is  pressed  with  the  finger  backward  toward  the  abdominal  cavity, 
while  deep  sutures  are  passed  which  take  hold  of  the  lateral  structures  of 
the  canal  and  also  back  up  the  twisted  sac.  If  the  sac  is  large  a  portion  :if 
its  fundus  should  be  excised.  The  skin  wound  is  closed  by  continuous 
sutures. 

LEVINGS'  OPERATION. 

A.  H,  Levings  (American  Journal  of  Surgery  and  Gynecology,  Feb- 
ruary, 1905)  employs  an  operation  for  the  cure  of  congenital  hernia  in 
the  canal  of  Nuck,  which  is  practically  the  same  as  the  operation  recom- 
mended by  me.  The  incision  is  made  parallel  to  the  inguinal  canal,  ex- 
tending one-half  an  inch  internal  to  the  external  ring,  and  passing  along 
the  course  of  the  canal  to  the  region  of  the  external  ring.  The  aponeurosis 
of  the  external  oblique  muscle  is  divided  to  the  upper  border  of  the  internal 
ring.  When  practicable,  the  peritoneal  process  should  be  separated  from 
the  cord  up  to  the  internal  border  of  the  internal  ring,  where  it  is  ligated 
and  cut  away. 

If  it  is  found  difficult  to  separate  the  peritoneal  sac  from  the  tissues 
of  the  round  ligament,  all  of  these  structures  may  be  dissected  up  to  the 
internal  ring,  where  they  are  ligated  and  cut  away.  In  these  cases  a  stout 
catgut  suture  should  be  carried  through  the  pillars  of  the  internal  ring  and 
the  stump  of  the  cut  cord  and  sac  so  as  to  fix  the  cord  in  this  position 
and  give  anterior  support  to  the  uterus.  Three  or  four  heavy  sutures  of 
catgut  should  be  passed  through  the  shelving  portion  of  Poupart's  liga- 
ment and  made  to  pick  up  the  internal  oblique  and  transversalis  muscles 
in  the  form  of  mattress  sutures,  thus  bringing  down  the  internal  oblique 
and  transversalis  muscles  and  closing  the  internal  oblique  and  inguinal 
canals.  In  closing  the  incision  in  the  aponeurosis  of  the  external  oblique, 
the  sutures  should  take  up  at  the  same  time  a  portion  of  the  internal 
oblique  muscle,  so  as  to  make  of  all  three  layers  one  solid  mass  of  tissue. 


PLATE   XLIV. 

Ferguson's  Operation  for  Inguinal  Hernia. 
T.  F.  Transversalis  fascia.     I.  R.  Internal  ring.     P.  L.  Poupart's  liga- 
ment.    I.  O.  Internal  oblique  muscle.     A.  Aponeurosis  of  external  oblique. 
C.  Cremaster  muscle.     C.  T.  Conjoined  tendon. 


OPERATIOXS    FOR    IXGUIXAL    HERNIA  253 

POULLET'S  OPERATION. 

J.  Poullet  (Lyon  Medicale,  Xo.  24,  190 ij  brought  forward  a  method 
for  the  radical  cure  of  hernia,  which  does  away  with  the  necessity  of 
rest  in  bed.  In  this  method  the  peritoneal  cavity  is  not  opened,  nor  is 
there  any  dissection  of  the  sac,  a  single  cut  of  the  bistoury  being  all  that 
is  necessary  to  incise  the  skin.  The  rest  of  the  operation  is  done  v/ith  the 
fingers,  a  tubular  needle,  and  a  large  metallic  thread.  This  thread  takes 
the  place  of  the  subcutaneous  truss.  Poullet  has  operated  over  four  hun- 
dred times  by  this  method.  At  first  there  were  some  recurrences,  but 
these  have  become  more  and  more  infrequent.  In  no  case  did  the  operation 
aggravate  the  patient's  condition. 

Poullet  operates  without  any  assistance ;  he  has  never  ligated  a 
vessel,  and  as  a  rule  the  operation  requires  about  fifteen  minutes.  The 
wire  he  uses  is  steel,  three-tenths  millimeters  in  diameter,  39  inches  .weigh 
I  gram,  7  or  8  inches  are  required  for  each  case,  and  the  same  method  is 
used  whether  the  hernia  is  inguinal,  femoral  or  umbilical  in  type. 

The  skin  incision  having  been  Inade,  the  neck  of  the  sac  is  isolated  with 
the  fingers,  and  a  long  forceps  is  placed  on  the  sac  to  prevent  its  descent. 
A  fine  tubular  needle  is  passed  through  the  neck  of  the  sac  five  or  six 
times,  below  the  forceps,  the  metallic  suture  is  placed  through  the  needle, 
not  including  the  vas  deferens  or  the  vessels  and  nerves,  to  the  cord.  In 
the  second  stage  of  the  operation  the  two  ends  of  the  suture  are  made  to 
traverse  the  whole  abdominal  wall,  except  the  skin,  from  within  out  to 
about  fifteen  millimeters  from  the  upper  border  of  the  external  ring.  To 
do  this,  the  left  index  finger  is  introduced  deeply  into  the  inguinal  canal 
and  the  needle  passed  between  it  and  the  abdominal  wall  which  it  per- 
forates from  within,  thus  implanting  the  two  ends  of  the  suture  an  inch 
apart.  The  third  step  is  to  close  the  canal  by  means  of  the  two  ends  of 
the  same  suture.  The  finger  still  remains  in  the  canal  to  guide  the  curved 
needle  which  perforates  the  abdominal  vv'all  from  within  out,  or  from 
without  in.  This  needle  brings  each  suture  successively  through  the  two 
fibro-muscular  borders  of  the  opening  to  be  closed,  each  border  is  trav- 
ersed three  or  four  times,  according  to  the  size  of  the  opening.  Poullet 
advises  not  to  tighten  the  suture  at  the  bottom  until  the  last  insertion  has 
been  made  below  the  ring  in  the  fibro-periosteal  tissue  near  the  pubic  spine. 

The  two  ends  of  the  suture  are  brought  together,  not  pulling  on  the 
suture,  nor  trying  to  bring  the  pillars  in  contact.  They  are  brought  closer, 
but  not  in  contact,  the  wire  being  the  barrier.  The  tw^o  ends  are  twisted  to- 
gether and  a  perforated  shot  is  placed  on  the  ends  so  that  the  tissues  will  not 
be  lacerated. 

DTJPLAY  AND  COZIN'S  METHOD. 

Duplay  and  Cazin  about  ten  years  ago  devised  an  operation  for  the 
cure  of  hernia  in  which  buried  sutures  were  discarded  entirely.  They  tied 
the  sac  on  itself,  split  its  distal  portion,  tying  a  series  of  knots,  or  the 
sac  was  divided  primarily  and  one-half  tied  to  the  other.  The  wound  was 
closed  with  silver  wire,  which  was  removed  after  union  had  taken  place. 


254 


OPERATIONS    FOR    INGUINAL    HERNIA 


SYMONDS'  OPERATION. 

In  the  Lancet,  Feb.  2,  1901,  T.  H.  Wells  describes  an  intra-peritoneal 
method  for  the  radical  cure  of  inguinal  liernia  performed  by  Symonds.  The 
operation  is  divided  into  seven  stages:  (i)  An  incision  two  and  a  half  inches 
long  in  the  linea  semilunaris,  ending  over  the  external  ring  and  passing 
through  the  skin,  fat.  superficial  and  deep  fascia;  (2)  deepen  the  upper  one 
and  a  half  inches  through  the  abdominal  muscles,  transversalis  fascia  and 
subperitoneal  fat,  and  having  arrested  all  hemorrhage,  open  the  peritoneal 
cavity;  (3)  explore  the  sac  with  the  finger  and  replace  the  intestine;  (4)  in- 
sert forceps  along  the  palmar  surface  of  the  finger,  seize  the  apex  of  the  sac 
and  invert  it,  bringing  it  out  into  the  upper  wound;  (5)  stitch  the  sac.  after 
giving  it  a  couple  of  twists  on  itself  to  obliterate  its  cavity,  through  the  peri- 
toneum; (6)  stitch  up  the  external  ring  and,  (7)  close  the  wound  by  bring- 
•  ing  the  structures  layer  by  layer  into  accurate  apposition. 

Symonds  claims  for  this  operation  that  it  is  expeditious;  the  neck  of 
the  sac  is  obliterated  high  up ;  the  inverted  sac  aids  in  forming  a  firm  scar ; 
the  sac  and  contents  can  be  explored  and,  if  necessary,  the  sac  opened  below 
quickly  and  safely;  the  incision  allows  any  method  of  closing  the  inguinal 
canal  and  external  ring. 

TOREK'S  OPERATION. 

Franz  Torek  {Annals  of  Surgery,  May,  1906)  describes  an  operation 
which  he  has  employed- in  cases  where  an  appendectomy  was  necessary 
at  the  same  time  that  operation  was  done  for  the  relief  of  a  hernia. 

An  imaginarv  line  is  drawn  from  the  anterior  superior  spine  of  the 
ileum  to  the  umbilicus.  A  point  on  this  line  at  a  distance  equal  to  one- 
quarter  of  its  length  from  the  iliac  spine  marks  the  beginning  of  the  in- 
cision, which  is  carried  down  from  here  to  the  external  inguinal  ring.  The 
aponeurosis  of  the  external  oblique  is  exposed  throughout  the  length  of 
the  incision.  This  fascia  is  then  incised  in  the  direction  of  its  fibers,  as  is 
customary  in  the  gridiron  operation  for  appendicitis,  exposing  the  internal 
oblique  muscle ;  but  the  incision  is  prolonged  downward  so  as  to  terminate 
at  the  apex  of  the  external  inguinal  ring. 

The  aponeurosis  of  the  external  oblique  is  pared  off  from  the  underlying- 
parts  in  the  usual  manner,  on  the  outer  side  exposing  Poupart's  ligament. 
Then  the  hernia  operation  is  proceeded  with  up  to  the  point  where  the 
sac  is  cut  oft'.  Here  the  hernia  operation  is  intermitted  and  attention  turned 
to  the  appendix. 

The  fibers  of  the  internal  oblique  and  transversalis  muscles  are  separated 
bluntly  in  the  usual  manner,  the  peritoneum  is  opened,  and  the  appendix 
removed ;  then  the  peritoneum,  transversalis  fascia  and  muscles  are  closed 
again.  The  appendicitis  operation  is  completed,  except  that  the  aponeurosis 
of  the  external  oblique  is  still  left  open.  Next  the  internal  oblique  and 
transversalis  are  sutured  to  Poupart's  ligament,  according  to  any  of  the 
approved  methods,  and  finally  the  aponeurosis  of  the  external  oblique  is 
sutured  in  the  entire  extent  of  its  incision,  so  as  to  close  both  the  appen- 
dicitis and  the  hernia  operation.     Lastly  the  skin  is  sutured. 


PLATE  XLV. 

Ferguson's  Operation  for  Inguinal  Hernia. 
A.  Aponeurosis  of  external  oblique.     I.  O.  Internal  oblique.     C   Cord. 
C.  T.  Conjoined  tendon.     P.  L.  Poupart's  ligament. 


OPERATIONS  FOR  IXGUIXAL  HERNIA  '    25/ 

Torek  claims  that  the  combined  operation  has  decided  advantages  over 
the  performance  of  the  two  operations  at  separate  sittings.  It  saves  the 
patient  one  operation  and  it  takes  only  very  little  longer  than  the  hernia 
operation  alone  would  require.  Furthermore,  there  is  greater  firmness  of 
the  abdominal  wall,  as  it  is  certainly  better  to  have  one  incision  in  the 
aponeurosis  than  two. 

I  have  frequently  removed  the  appendix  in  the  course  of  a  herniotomy. 
For  some  time  past  I  have  made  it  a  practice  to  explore  the  abdominal 
cavity  by  passing  my  hand  and  arin  in  through  the  hernial  incision  in 
cases  where  disease  of  internal  organs  was  suspected.  Sufficient  room  to 
accomplish  this  is  obtained  by  separating  the  internal  oblique  and  the  trans- 
versalis  muscles  from  Poupart's  ligament.  When  the  patient  is  suffering 
with  chronic  appendicitis  and  also  has  a  hernia,  I  prefer  to  make  a  single 
incision,  that  for  the  hernia,  to  deal  with  both  conditions. 


CHAPTER  II. 

OPERATIONS  FOR  INGUINAL  HERNIA. 
(Continued.) 

BUTLER'S  OPEEATION. 

C.  A.  Butler  has  devised  a  modification  of  the  Halsted  operation.  A 
skin  incision  is  made  parallel  to  Ponpart's  ligament  and  three-fourths  of 
an  inch  internal  to  it,  extending  from  a  point  slightly  beyond  the  internal 
abdominal  ring  to  the  spine  of  the  pubes.  The  subcutaneous  tissues  are 
divided  in  their  turn  the  full  length  of  the  skin  incision.  The  external 
oblique  is  first  incised  parallel  to  the  direction  of  its  own  fibers,  then  the 
internal  oblicjue  and  transversalis  are  cut,  and  finally  the  transversalis  fascia 
having  been  divided,  the  spermatic  canal  is  fully  exposed  from  the  internal 
to  the  external  abdominal  ring,  thus  bringing  into  view  the  cord.  The  vas 
deferens  is  isolated  and  if  there  is  any  tendency  to  enlargement  of  its  ac- 
companying veins  all  but  two  or  three  are  ligated,  above  and  below,  and 
dissected  out.  -  ■' 

The  subcutaneous  incision  is  extended  five-eighths  of  an  inch  or  more 
beyond  the  internal  ring,  in  order  to  release  the  constriction  and  to  get 
firm,  fresh  tissue  from  which  to  build  the  new  exit  for  the  cord.  Follow- 
ing this  the  sac  is  opened,  its  contents  carefully  examined  and  replaced 
within  the  abdomen. 

A  ligature  of  catgut  is  now  passed  around  the  neck  of  the  sac  close 
to  the  internal  ring  and  the  sac  is  cut  away.  The  ends  of  the  ligature  which 
have  been  left  long  are  threaded  separately  through  long  curved  needles, 
passed  eye-end  first  through  the  abdominal  opening  alongside  of  the  stump 
of  the  sac  and  brought  out  a  quarter  of  an  inch  apart  through  the  internal 
oblique  muscle  at  a  point  one  and  one-half  inches  internal  to  the  upper 
angle  of  the  incision,  where  gentle  traction  is  made  to  draw  the  stump  of 
the  sac  away  from  the  field  of  operation,  when,  by  tying  the  ligature, 
the  stump  is  held  in  a  permanently  displaced  position.  Any  cicatricial 
mass  or  tissue  of  questionable  vitality  is  dissected  away  from  about  the  old 
internal  abdominal  ring.  Each  muscular  layer  is  sutured  separately,  allow- 
ing the  edges  to  overlap  as  much  as  the  tension  will  allow,  until  the  ex- 
ternal oblique  is  reached. 

Instead  of  suturing  the  aponeurosis  of  the  external  oblique  in  a  direct 
line,  as  in  case  of  the  other  layers,  a  strip  one-half  inch  wide  and  one 
and  one-half  inches  long  is  cut  from  the  internal  border  of  the  external 
oblique  at  a  point  directly  opposite  the  site  of  the  new  ring,  leaving  the 
upper  end  of  the  strip  fast  and  passing  the  loose  end  under  the  cord  and 
suturing  it  to  the  superior  surface  of  Poupart's  ligament.  This  gives  a 
firm   ring  with  the  fibers   running  crosswise   to   the   direction   of   greatest 


OPERATIONS    FOR    INGUINAL    HERNIA  259 

strain.  The  remainder  of  the  aponeurosis  is  sutured  below  this  loop  in 
the  same  manner  as  the  underlying  structures,  using  silk  or  fine  silver 
wire.  Butler  says  that  this  portion  of  the  method  was  employed  by  the 
late  W.  V.  Morgan,  of  Indianapolis,  for  two  years  prior  to  his  death  and 
since  that  time  by  himself,  together  in  more  than  fifty  cases,  with  uniformly 
good  results. 

The  hernia  now  having  been  reduced,  the  stump  of  sac  displaced  away 
from  the  operative  field,  the  cord  located  on  its  new  bed  and  the  hernial 
opening  obliterated,  all  that  remains  to  be  done  is  to  suture  the  skin  with 
kangaroo  tendon  and  to  apply  a  dry  dressing. 

TREVES'  OPERATION. 

Treves  performs  an  operation  which  is  a  modification  of  Macewen's. 
The  sac  is  twisted  on  itself  and  a  part  of  it  is  cut  away  and  passed  be- 
neath the  conjoined  tendon.  It  is  brought  out  through  an  opening  made 
near  the  median  line,  and  is  fixed  by  sutures. 

BISHOP'S  OPERATION. 

In  selected  cases  Bishop  invaginates  the  sac  and  turns  it  into  the 
.abdominal  cavity  inside  out,  fixing  it  at  the  internal  ring  so  as  to  form 
a  boss. 

SMITH'S  OPERATION. 

A.  C.  Smith  employ's  the  following  method  for  the  radical  cure  of 
congenital  inguinal  hernia :  After  forming  a  tunic  for  the  testis  out  of 
the  lower  end  of  the  sac,  the  remainder  of  the  sac,  except  the  strip  which 
lies  immediately  on  the  vas  and  its  vessels  and  nerves,  is  trimmed  away 
close  to  the  abdominal  cavity.  The  simple  wound  of  the  peritoneum  is 
closed  with  a  continuous  suture,  one  extremity  ending  at  the  cord.  The 
transversalis  fascia  is  sutured  either  with  the  peritoneum  or  separately, 
and  the  operation  is  completed  according  to  the  Bassini  method.  The 
strip  which  is  left  attached  to  the  cord,  consisting  of  peritoneal  membrane, 
does  not  interfere  with  the  closure  of  the  openings  in  the  sac. 

WHITE'S  OPERATION. 

J.  W.  White,  believing  that  some  of  the  failures  following  Bassini's 
operation  might  be  accounted  for  on  the  ground  that  union  failed  to  occur 
between  two  muscles  or  the  edges  of  muscular  tissue  unless  the  edges  are 
freshened,  suggested  cutting  out  an  inverted  V-shaped  piece  of  tissue  in  the 
external  oblique  muscle,  w^hich  makes  this  muscle  re-enforce  the  weak  place 
in  the  abdominal  wall  at  the  internal  oblique  muscle  and  Poupart's  liga- 
ment. He  suggested  a  variety  of  methods  to  be  used  to  close  the  hernial 
openings  with  muscular  tissue. 

In  cases  in  which  the  muscular  walls  have  been  stretched  and  are 
very  lax  he  suggests  raising  the  edge  of  the  internal  oblique  and  exposing 
the  outer  edge  of  the  transversalis.  An  inverted  V-shaped  piece  of  this 
muscle  is  excised,  making  a  round  opening  for  the  cord  to  pass  through ;  a 


260  OPERATIONS  FOR  INGUINAL  HERNIA 

piece  is  also  cut  out  of  the  transversalis.  The  cut  edges  are  united  with 
sterile  catgut.  This  will  make  tense  the  lower  edge  of  the  transversalis 
muscle,  drawing  it  down  and  closing  the  opening  of  the  internal  wound 
with  muscular  tissue.  The  lower  edge  of  the  internal  oblique  is  replaced 
and  the  cord  raised;  the  sutures  are  then  inserted  into  the  internal  oblique 
and  Poupart's  ligament,  as  in  Bassini's  operation,  thus  making  a  combined 
operation. 

DAVIS'  OPERATION. 

G.  G.  Davis  (Annals  of  Surgery,  Janviar_v,  1906)  presented  a  modifi- 
cation of  the  operation  usually  done  for  the  cure  of  a  direct  inguinal  hernia. 
In  cases  of  oblique  hernia  the  cremaster  fibers  are  sometimes  quite  abun- 
dant, and  may  be  utilized  to  close  the  canal,  but  in  direct  hernia  these  fibers 
are  apt  to  be  too  scanty  to  be  of  any  service.  When  the  hernia  is  an  old 
one,  he  divides  the  sac  transversely  and  overlaps  these  tvv'o  parts,  suturing 
the  apex  of  the  lower  flap  to  the  base  of  the  upper,  and  then  bringing 
down  the  upper  flap  and  suturing  it  in  place,  as  is  dene  in  the  Ma,yo  opera- 
tion for  umbilical  hernia,  but  without  dissecting  off  the  peritoneum,  which 
is  firmly  blended  with  the  other  tissues  and  adds  considerably  to  the 
strength  of  the  flap ;  whereas  alone  it  is  too  weak  to  be  of  much  service. 
\^''hen  the  peritoneum  is  not  adherent  to  the  conjoined  tendon  and  inter- 
columnar  fascia  in  front,  but  has  a  layer  of  fat  between,  the  fat  may  be 
scraped  away  and  the  two  laid  together  and  treated  as  a  single  layer  and 
overlapped. 

Davis  believes  that  the  overlapping  plan  has  been  found  to  work 
satisfactorily  in  cases  of  oblique  inguinal  hernia  and  umbilical  hernia  and 
that  it  also  will  be  found  of  value  in  certain  cases  of  direct  inguinal  hernia. 

DENTIT'S  OPERATION. 

Dentu's  method  is  very  similar  to  Bassini's.  The  primary  incision 
is  made  exactly  the  same  way.  The  aponeurosis  of  the  external  oblique  is 
carefully  exposed,  but  not  divided.  The  sac  is  separated  from  the  cord 
and  other  attachments  as  high  up  as  the  internal  ring.  A  small  opening 
is  then  made  in  the  aponeurosis  at  one  side  of  the  internal  ring,  and  through 
this  is  passed  a  long  forcep  which  grasps  the  fundus  of  the  sac  and  draws 
the  latter  through  the  opening.  The  neck  of  the  sac  is  then  iigated  and 
returned  to  the  abdomen  and  included  in  the  mattress  sutures  which  close 
the  opening  in  the  aponeurosis.  The  redundant  anterior  wall  of  the  canal 
is  folded  on  itself  parallel  to  its  long  axis  and  secured  in  this  position  by 
mattress   sutures. 

KENNEDY'S  OPERATION. 

In  Kennedy's  operation  the  sac  is  dealt  with  by  Kocher"s  latest  method. 
It  is  invaginated  into  the  abdomen  and  brought  out  through  the  abdominal 
wall.  The  ligature  is  then  cut  off  and  the  internal  oblique  and  transversalis 
are  stitched  to  the  deep  aspect  of  Poupart's  ligament,  but  without  cutting 
the  external  oblique  tendon.     The  cord  is  not  transplanted.     Among  fifty- 


.  PLATE   XLVI. 

Ferguson's  Operation  for  Inguinal  Hernia. 
A.  Aponeurosis  of  external  oblique.     P.  L.  Poupart's  ligament.     I.  O. 
Internal  oblique.     T.  F.  Transversalis  fascia.     C.  Cremaster  muscle. 


OPERATIONS    FOR    INGUINAL    HERNIA  263 

four  patients  operated  on  by  Kennedy  according  to  this  method  there  was 
only  one  case  of  relapse. 

OWEN'S  OPERATION. 

The  operation  performed  by  Owen  to  cure  inguinal  hernia  occurring 
in  boys  is  a  good  deal  like  that  of  Mitchell-Banks,  except  that  Owen  passes 
the  sutures  deeply  through  Poupart's  ligament,  and  the  muscular  inner 
wall  of  the  inguinal  canal,  so  as  to  keep  them  in  permanent  contact.  The 
stitches  cause  the  deposit  of  a  large  amount  of  plastic  exudation,  which 
in  the  course  of  time  is  replaced  by  fibrous  tissue  which  makes  a  splendid 
barrier. 

No  doubt  Owen,  whose  experience  has  been  very  extensive,  is  aware 
of  the  fact  that  almost  any  operative  procedure  will  cure  a  hernia  occurring 
in  boys,  provided  the  muscular  development  of  the  patient  is  normal. 

BARNHILL'S  OPERATION. 

J.  U.  Barnhill  has  devised  an  improvement  of  the  Bas?ini  operation, 
which,  in  my  opinion,  is  as  irrational  in  principle  as  is  the  operation  which 
it  is  intended  to  modify.  In  Barnhill's  operation  the  skin  and  superficial 
fascia  are  divided  from  the  spine  of  the  pubis  to  slightly  beyond  the  inter- 
nal abdominal  ring.  The  external  oblique  aponeurosis  is  divided  to  about 
the  same  point,  leaving  the  lower  flap  of  fairly  good  width.  The  sac  is 
then  carefully  separated  from  the  cord,  opened  to  free  it  of  intestine,  trans- 
fixed, ligated  high  up,  and  excised,  when  it  will  retract  through  the  internal 
ring.  If  there  are  varicose  veins  in  the  spermatic  cord  the  largest  are 
ligated  and  excised.  The  cord  being  held  up  out  of  the  way,  the  transver- 
salis  fascia  and  internal  oblique,  including  the  conjoined  tendon,  are  then 
stitched  to  the  shelving  portion  of  Poupart's  ligament,  two  stitches  being 
placed  in  the  internal  oblique  muscle  above  the  opening  for  the  passage 
of  the  cord  to  gather  up  the  muscle  and  fascia,  with  a  view  of  obliterating 
the  inguinal  fossa,  care  being  taken  to  bring  the  cord  well  down  to  the 
lower  border  of  the  internal  oblique,  thus  giving  it  considerable  obliquity 
in  passing  beneath  these  muscles.  Mattress  sutures  are  then  passed 
through  the  lower  flap  close  to  Poupart's  ligament — that  is,  in  the  lower 
portion  of  the  outer  flap — catching  the  margin  of  the  internal  oblique  and 
its  fascia  and  the  lower  margin  of  the  upper  or  internal  flap.  Three  such- 
mattress  sutures  are  placed  in  the  upper  part  of  the  incision  over  the  muscle 
and  cord,  the  other  four  being  passed  beneath  the  cord. 

A  small  incision,  sufficient  to  niake  an  opening  large  enough  for  the 
passage  of  the  cord,  is  made  in  each  flap ;  in  the  upper  one  at  a  point  an 
half  inch  below  that  at  which  the  cord  passes  out  through  the  internal 
oblique,  and  the  one  in  the  lower  flap  at  the  junction  of  its  lower  and 
middle  third.  The  mattress  sutures  are  then  tied  and  the  cord  passed 
through  the  opening  in  the  upper  flap.  The  lower  flap  is  then  carried  up- 
ward over  the  cord  and  stitched  to  the  upper  flap  above  the  cord,  except 
the  lower  third,  which  is  passed  beneath  the  cord  and  stitched  in  like  man- 


264  OPERATIONS  FOR  INGUINAL  HERNIA 

ner.     Both  layers  of  the  superficial  fascia  are  then  approximated  and  the 
wound  closed  with  a  subcuticular  silkworm-gut  suture. 

BEAVER'S  OPERATION. 

John  B.  Deaver,  of  Philadelphia,  prefers  to  use  a  combination  of  the 
Macewen  and  Bassini  operations.  The  anterior  wall  of  the  inguinal  canal, 
excepting  the  lower  fibers  of  the  internal  oblique  muscle,  is  divided,  the 
sac  freed,  and  replaced  at  the  internal  ring  after  the  manner  of  the  Macewen 
operation.     The  canal  is  then  closed  as  in  the  Bassini  operation. 


CHAPTER  III. 

OPERATIONS  FOR  INGIINAL  HERNIA. 
(Continued.) 

ANDREWS'  IMBRICATION  METHOD. 

E.  Wyllys  Andrews,  of  Chicago,  advocates  overlapping  the  aponeuro- 
sis of  the  external  oblique  muscle  in  the  case  of  large  hernias  where'  there 
is  a  marked  anatomical  defect,  and  in  cases  of  long-standing,  where  the 
aponeurosis  is  redundant  and  where  it  is  better  to  imbricate  than  to  re- 
move or  plicate  it.  The  internal  lip  of  the  cut  aponeurosis  is  sutured  to 
Poupart's  ligament  under  the  cord,  and  the  lower  flap  of  the  aponeurosis 
is  brought  up  over  the  cord  and  fastened  to  the  anterior  surface  of  the 
aponeurosis  along  the  inner  border  of  the  cord.  Andrews  overlaps  these 
structures  (Fig.  38),  no  matter  whether  the  Bassini  operation  or  that  of 
the  author  is  performed.  The  overlapping  can  be  done  in  front  of  or 
behind  the  cord,  or  the  cord  may  be  placed  between  the  flaps.  The  imbri- 
cation gives  broad  surfaces  for  union  and  by  this  means  an  opening  of  any 
size  can  be  covered  with  a  stout  fibrous  layer. 

While  I  fully  agree  with  Andrews  that  imbrication  of  the  aponeurosis 
of  the  external  oblique  muscle  is  desirable  to  obtain  additional  strength  in 
the  inguinal  region,  and  I  have  always  practised  it  in  suitable  cases  ever 
since  I  saw  Macewen  do  it  in  1889,  still  in  a  rational  operation  sight  must 
not  be  lost  of  (a)  the  slack  of  the  transversalis  fascia  at  the  internal  ring 
and  its  correction;  (b)  the  arched  up  and  often  deii-cient  internal  oblique 
muscle  and  its  restoration  to  its  normal  position;  (c)  the  normal  position 
of  the  cord  and  that  its  removal  from  its  bed  invites  a  relapse  of  the  her- 
nia; and  (d)  we  must  not  leave  a  weakened  conjoined  tendon  unpro- 
tected. It  is  not  indicated  to  overlap  the  flaps  of  the  aponeurosis  when 
undue  tension  is  required  to  hold  them  in  the  imbricated  position. 

NOBLE'S  OVERLAPPING  OPERATION. 

C.  P.  Noble  has  for  some  time  made  use  of  an  operation  in  which 
the  peritoneum  is  first  closed  with  a  continuous  suture  of  fine  cumol  catgut. 
The  fat  is  then  dissected  from  the  upper  surface  of  the  aponeurosis  of  the 
transversus  muscle  on  the  left  side  of  the  wound  over  one-third  to  one-half 
inch.  The  aponeurosis  on  the  right  side  of  the  wound  is  then  separated 
for  an  equal  distance  from  the  rectus  muscle.  The  muscle  and  fascia  are 
then  sutured  by  means  of  a  medium  weight  chromicized  catgut  suture. 

The  suturing  is  begun  at  the  lower  angle  of  the  wound  on  the  left 
side,  the  suture  being  passed  from  above  downward  through  the  aponeu- 
rosis and  rectus  muscle.  Then  the  separated  bundles  of  the  rectus  muscle 
are  united  with  a  continuous  suture  until  the  upper  angle  of  the  wound 


266  OPERATIONS    FOR    INGUINAL    HERNIA 

is  reached,  when  the  suture  is  passed  from  below  upward  through  the 
aponeurosis  on  the  left  side  of  the  wound.  The  suture  is  then  passed  from 
below  upward  through  the  aponeurosis  on  the  right  side  of  the  wound 
and  an  additional  suture  is  taken  above  this  point  to  fix  the  suture  and 
to  take  the  strain  off  that  part  v*diich  has  brought  the  muscle  into  apposi- 
tion. The  aponeurosis  is  then  closed  from  above  downward  by  catching 
the  aponeurosis  over  the  left  side  of  the  wound  after  the  manner  of  the 
Lembert  intestinal  suture,  and  then  passing  the  needle  from  below  upward 
through  the  aponeurosis  on  the  right  side  of  the  w^ound.  When  this 
suture  is  drawn  taut,  it  slides  the  aponeurosis  of  the  right  side  of  the 
wound  on  the  aponeurosis  of  the  left  side.  The  process  is  repeated  until 
the  upper  angle  is  reached,  when  the  two  ends  of  the  suture  are  tied. 

In  long  wounds  two  or  more  mattress  sutures  are  placed  to  take  the 
tension  off  the  lines  of  continuous  suture.  The  fat  is  closed  wdth  a  con- 
tinuous suture  of  fine  cumol  catgut.  This  is  also  used  to  close  the  skin 
by  means  of  the  intra-cuticular  method.  In  1898  Noble  abandoned  silk- 
worm gut  sutures,  and  the  continuous  chromicized  catgut  suture  for  the 
rectus  muscle  and  for  the  aponeurosis  was  substituted.  This  method  is 
employed  for  celiotomies,  herniotomies  and  the  Alexander  operation. 

FREEMAN'S  OPERATION. 

The  operation  employed  by  L.  Freeman  is  really  a  new  method  of 
suturing.  Before  the  operation  is  begun  two  or  three  needles  are  threaded 
with  long  loops  of  silkworm  gut  or  silver  wire.  Two  pieces  of  stiff"  silver 
wire  are  taken,  long  enough  to  reach  the  entire  length  of  the  inguinal 
canal.  The  internal  ring  is  exposed ;  the  sac  is  ligated  and  cut  off,  and 
the  cord  is  held  out  of  the  way.  One  of  the  silkworm  loops  is  passed  from 
without  inward  through  the  muscle  tissue  on  the  umbilical  side  of  the  ring, 
wxll  back  from  the  margin,  and  tolerably  close  to  the  point  of  exit  of  the 
cord.  The  loop  is  then  carried  through  Poupart's  ligament  from  within 
outward.     Another  loop  is  inserted  near  the  pubic  end  of  the  opening. 

One  of  the  pieces  of  prepared  wire  is  run  through  the  loops,  which 
are  pulled  tight  enough  to  hold  it  in  place.  The  other  wire  is  laid  along 
Poupart's  ligament  between  the  free  ends  of  the  loops  which  are  tied 
firmly  over  it.  The  wires  are  thus  approximated.  To  facilitate  the  removal 
of  the  wires  they  are  bent  upward  at  their  pubic  extremities  so  as  to  pro- 
trude through  the  external  incision.  The  cord  is  dropped  in  place  over 
the  line  of  union  and  the  aponeurosis  of  the  external  oblique  muscle  is 
united  above  it,  the  upturned  ends  of  the  wires  passing  through  the  ex- 
ternal ring.  This  aponeurosis  can  be  sutured  either  with  removable  suture 
or  with  catgut  because  this  structure  is  not  subjected  to  tension. 

In  uniting  the  skin  the  free  ends  of  the  loops  and  the  ends  of  the  wires 
are  brought  out  through  the  incision  between  the  stitches.  In  from  ten 
days  to  two  weeks  the  wires  are  removed.  This  frees  the  loops,  which  are 
likewise  extracted. 


PLATE  XLVTI. 

Diagram  of  the  position  of  the  transplanted  rectus  muscle,  demon- 
strating the  slight  change  in  the  direction  of  its  fibers. — Bloodgood's  opera- 
tion.    (Johns  Hopkins  Hospital  Report.     Vol.  VH.) 


OPERATIONS    FOR    INGUINAL    HERNIA  269 

M'ARTHUR'S  AUTOPLASTIC  SUTURE. 

L.  L.  McArthur,  of  Chicago,  takes  his  suture  material  from  the  aponeu- 
rosis of  the  external  oblique  muscle.  He  claims  that  the  grafted  suture 
remains  as  fibrous  tissue,  or  if  it  dies  and  becomes  absorbed  after  a  pri- 
mary union  has  taken  place,  it  accomplishes  all  that  is  accompHshed  by 
foreign  suture  material;  whereas,  if  the  suture  lives,  as  his  experiments 
seemed  to  prove  was  the  case,  it  remains  to  offer  a  permanent  resistance  to 
future  stretching  (Figs.  39  and  40). 

The  skin  and  fat  having  been  cut  by  the  usual  incision  exposing  the 
external  ring,  the  latter  is  prolonged  upward  in  the  usual  manner,  but  to 
its  commencing  muscular  insertion.  Special  care  is  taken  to  parallel  the 
tendinous  fibers.  This  divides  the  aponeurosis  into  an  external  and  internal 
flap,  each  of  which  can  be  readily  separated  from  its  contact  with  the 
internal  oblique. 

The  sac  having  been  treated  as  the  operator  deems  best,  a  bundle  of 
those  white  fibers  which  enter  into  the  formation  of  the  internal  pillar  of 
the  ring  is  then  split  off,  from  below  upward,  from  the  edge  of  the  internal 
flap  of  the  aponeurosis  of  the  external  oblique,  quite  up  to  its  termination 
in  the  muscle  belly.  Above  it  is  cut  loose,  but  left  attached  to  the  pubic 
spine  below.  This  strip  should  vary  in  Avidth  from  one-eighth  to  three- 
sixteenths  of  an  inch,  according  to  the  development  of  the  tendon.  An 
identically  similar  strip,  beginning  in  the  external  pillar  of  the  ring,  is  taken 
from  the  outer  flap  of  the  external  oblique.  At  this  stage  the  suturing  is 
to  be  done. 

The  operation  is  completed,  according  to  the  choice  of  the  operator, 
bv  the  Bassini,  an  Andrews  imbrication,  or  Girard  method,  using  these 
strips  as  suture  material  for  a  running  stitch.  As  a  convenient  means 
of  handling,  and  for  the  purpose  of  avoiding  infecting  the  graft  suture,  a 
needle  threaded  with  No.  3  silk  is  tied  by  a  single  knot  to  its  free  end, 
and  bv  it  the  tendon  graft  is  drawn  through  the  tissues  to  be  united. 
Using  the  graft  ending  in  the  internal  pillar  for  the  first  or  deep  suture, 
the  surgeon  dra\vs  the  internal  oblique  and  transversalis  down  to  the 
inner  aspect  of  Poupart's  ligament,  as  shown  in  the  drawing,  suiting  his 
convictions  as  to  raising  or  not  raising  the  cord.  If  he  raises  the  cord 
(Andrews),  then  no  opening  is  left  below  for  an  external  ring;  if  the 
cord  is  not  raised  (Ferguson,  Bassini),  then  the  first  stitch  determines  the 
fit  of  the  external  ring  around  it. 

The  edges  of  the  external  oblique  are  then  sutured  with  a  running 
stitch,  using  the  graft  made  from  an  external  pillar  of  the  ring  when  a 
Bassini  is  being  done ;  to  the  surface  of  the  external  oblique  when  an 
Andrews  or  Girard  is  done.  The  ends  of  the  suture  strips  can  be  fixed 
by  a  simple  knot  in  it,  or  by  one  or  two  stitches  through  and  back,  as  a 
tailor  fixes  his  thread,  or  by  a  fine  catgut  stitch  wnth  the  graft  end  caught 
in  its  knot. 

The  deep  suture  penetrates  the  external  oblique  muscle  for  final  fixation 
after  the  new^  internal  ring  has  been  made.     The  skin  and  fat  are  approxi- 


270  OPERATIONS    FOR    INGUINAL    HERNIA 

mated  according  to  the  preference  of  the  surgeon.  A'lcArthur  emphasizes 
the  importance  of  Hberating  these  strips  of  aponeurosis  from  below  upward, 
and  not  from  above  downward,  because  the  fibers  often  curve  outward 
around  the  external  ring',  when  followed  in  the  latter  manner. 

HAEillS'  WIRE  SUTURE. 

M.  L.  Harris,  of  Chicago,  claims  that  wire  suture  can  be  employed 
advantageously  in  all  hernia  operations  (Fig.  41).  The  operation  is  per- 
formed in  the  usual  manner  up  to  the  stage  of  the  ablation  of  the  sac. 
Harris  claims  that  the  advantages  of  the  wire  used  by  him,  aluminum 
bronze,  Nos.  26  and  27,  are  its  greater  tensile  strength,  so  that  a  smaller 
wire  can  be  used,  and  the  fact  that  it  does  not  kink  so  readily.  The  wire 
can  be  easily,  quickly  and  certainly  sterilized  by  simply  placing  it  in  boil- 
ing water  with  the  instruments.  In  closing  a  median  incision  through 
the  abdominal  wall,  three  wire  sutures  are  used,  one  closing  the  peritoneum, 
one  in  the  sheath  of  the  rectus  muscle,  and  one  in  the  skin. 

The  sutures  are  introduced  in  the  following  manner :  A  No.  27 
aluminum  bronze  wire  is  threaded  directly  in  a  nearly  full-curved  round 
needle  with  a  specially  constructed  eye  for  carrying  wire  so  that  it  will 
not  slip  in  the  eye.  The  needle  is  made  to  enter  the  skin  in  the  midline, 
I  to  3  cm.  from  the  angle  of  the  incision,  and  penetrates  obliquely  all  the 
tissues  down  to  the  peritoneum,  where  it  should  appear  at  the  angle  of  the 
peritoneal  incision.  The  peritoneum  is  now  taken  up  with  the  needle, 
parallel  with  and  quite  near  to  its  edge,  first  on  one  side  and  then  on  the 
other,  constantly  in  an  advancing  manner  until  the  entire  length  of  the 
incision  has  been  traversed.  The  grasp  of  the  needle  should  not  be  more 
than  a  centimeter  in  length,  and  the  point  of  entrance  of  one  grasp  should 
be  opposite  the  point  of  exit  of  the  last  grasp.  The  suture  is  then  brought 
obliquely  to  the  surface  about  the  same  distance  from  the  cutaneous  angle 
as  at  its  point  of  entrance. 

The  second  suture,  wire.  No.  26,  enters  in  the  midline,  but  a  little 
nearer  the  angle  of  the  incision.  It  penetrates  as  far  as  the  sheath  of  the 
rectus  muscle,  where  the  edges  of  this  fascia  are  taken  up  longitudinally 
in  exactly  the  same  manner  as  has  just  been  described  for  the  peritoneum. 
No  sutures  are  applied  to  the  recti  muscles.  At  no  point  in  the  midline 
do  the  recti  muscles  lie  in  contact  with  one  another ;  hence,  m  closing  a 
median  incision,  it  is  unnecessary  to  suture  together  the  recti  muscles  with 
the  expectation  of  obtaining  union  between  them.  The  dense,  thick,  con- 
joined fascia,  of  the  linea  alba  in  the  upper  part  of  the  abdomen  or 
the  firm  anterior  layer  of  the  muscle  sheath  below  Douglas"  fold  is  the 
all-important  layer  to  be  sutured.  This  is  the  layer  m  which  the  most 
perfect  apposition,  edge  to  edge,  should  be  secured.  The  third  suture  is 
the  usual  subcutaneous  or  subcuticular  suture.  The  wire  enters  and  leaves 
at  the  angles  of  the  incision,  running  along  in  the  corium,  in  and  out,  in 
the  same  manner  as  has  been  described  for  the  other  two.  It  does  not  ap- 
pear on  the  skin  at  any  point,  except  where  it  enters  and  leaves.     After 


PLATE  XLVIII. 

Ferguson's  Operation  for  Inguinal  Hernia. 
{Ochsner's  Clinical  Surgery.) 


OrERATIONS    FOR    INGUINAL    HERNIA  2.^2^ 

the  wires  are   introduced  they  are   drawn  back  and   forth   until   they   are 
perfectly  straight  and  move  easily  through  the  tissues. 

The  wound  may  now  be  dressed  in  any  manner  one  chooses.  Thj 
method  Harris  uses  is  to  seal  the  line  of  union  with  silver  foil,  after  th.j 
method  of  Halsted.  On  this  he  places  a  compress  of  a  few  layers  of  plain 
sterile  gauze,  over  which  are  folded  the  ends  of  the  wires,  which  should 
be  left  long.  On  these  is  placed  another  similar  compress,  followed  by 
the  usual  dressing  of  plain  sterile  gauze  and  cotton.  The  wires  are  usually 
allowed  to  remain  two  weeks.  To  remove  the  wires,  they  should  be  drawn 
back  and  forth  gently  until  loosened  in  the  tissue,  then  one  at  a  time  cut 
close  to  the  skin  and  .withdrawn.  They  are  easily  removed  with  scarcely 
any  pain.  Care  should  be  taken  not  to  break  the  wires  by  pulling  sud- 
denly before  loosening  them.  In  closing  the  muscle-splitting  incision  in 
interval  operations  for  appendicitis,  one  wire  parallels  the  fibers  of  the 
internal  oblique  and  transversalis,  entering  and  leaving  the  skin  some 
distance  from  the  cutaneous  incision,  and  crossing  it  almost  at  right  angles. 
Another  wire  parallels  the  fibers  of  the  external  oblique,  and  a  third  forms 
the  subcuticular  suture. 

In  cases  of  inguinal  hernia  the  suture  is  applied  in  the  following  man- 
ner: 

The  needle  enters  the  skin  from  one  to  tv/o  centimeters  from  the 
inner  angle  of  the  incision,  passing  directly  down  to  and  taking  up  a 
"bite"  of  the  beginning  of  the  inner  edge  of  Poupart's  ligament.  A  "bite" 
about  one  centimeter  in  length  is  then  taken  directly  opposite,  including  the 
external  oblique  and  the  internal  oblique  and  transversalis,  or  so-called  con- 
joined tendon.  Then  a  "bite"  in  Poupart's  ligament,  passing  back  and  forth 
until  an  opening  only  large  enough  to  permit  the  passage  of  the  cord 
remains  at  the  outer  angle.  Passing  the  wire  beneath  the  cord,  it  is 
brought  out  through  the  external  oblique  and  skin  about  one  or  two  centi- 
meters from  the  outer  angle  of  the  incision. 

The  wire  should  be  pulled  back  and  forth  until  it  is  perfectly  straight 
and  moves  easily  in  the  tissues.  This  wire  is  very  easily  introduced  by 
paying  a  little  attention  to  a  few  points.  Place  a  snap  forceps  on  the  free 
end  of  the  wire  to  keep  it  taut.  Draw  each  stitch  taut  at  once.  Enter  at  a 
point  directly  opposite  the  point  of  the  last  stitch.  Take  each  "bite" 
parallel  with  the  edges  to  be  brought  together.  Do  not  make  an  over-and- 
over  stitch,  as  it  will  not  pull  out.     Do  not  allow  the  wire  to  kink. 

After  the  wire  is  in,  the  cord  is  laid  along  its  bed  and  the  lower  flap 
of  the  aponeurosis  of  the  external  oblique  covered  over  it  and  sutured  by 
wire  introduced  in  the  same  manner  as  the  first  (Fig.  41),  but  passing 
from  the  outer  to  the  inner  angle  of  the  incision,  leaving  an  opening  at 
the  external  abdominal  ring  just  large  enough  to  give  exit  to  the  cord. 
The  cutaneous  edges  are  now  brought  together  by  a  third  wire  on  a  cut- 
ting-needle passed  in  the  corium,  a  so-called  subcuticular  suture.  The 
incision  is  sealed  with  silver  foil,  a  pad  of  several  thicknesses  of  gauze 
placed  on  the  first  one,  and  the  whole  held  in  place  by  a  couple  of  strips 
of  adhesive  plaster.     The  wires  are  removed  at  the  end  of  two  weeks. 


274  OPERATIONS    FOR    INGUINAL    HERNIA 

There  is  one  criticism  that  I  wish  to  make  in  regard  to  the  manner 
in  which  the  first  wire  is  used  with  the  cord  raised  out  of  its  bed,  and 
that  is  this:  The  danger  of  injuring  the  cord  at  the  upper  and  also  the 
lower  angle  of  the  wound,  where  the  wire  hugs  it  closely.  This  danger  is 
obviated  by  not  raising  the  cord  out  of  its  bed  at  all,  and  insures  a  radical 
cure  even  better  than  the  method  of  Bassini  and  its  modifications. 

REMOVABLE  CONTINUOUS  SUTURES. 

L.  Gratschoff  employs  a  method  of  closing  the  inguinal  canal  which  he 
believes  offers  special  advantages.  He  uses  a  piece  of  steel  wire  about 
13  cm.  long,  terminating  in  a  small  perforated  ball  at  each  end.  Two 
small  hooks  to  hold  the  silk  thread  are  soldered  to  the  wire,  which  is  drawn 
up  into  the  shape  of  a  bow  after  it  has  been  introduced  into  the  inguinal 
canal.  After  the  hernia  has  been  taken  care  of,  one  end  of  the  wire  is 
introduced  through  the  incision  and  a  stout  silk  thread  is  fastened  to  one 
of  the  hooks  and  passed  through  the  end  of  the  wire  bow  and  then  around 
the  internal  and  then  the  external  pillar,  and  again  around  them,  until 
enough  stitches  have  been  taken.  The  needle  is  then  brought  out  through 
the  skin  and  the  silk  is  drawn  taut  and  fastened  to  the  other  end  of  the 
wire  bow.  Both  wire  and  sutures  are  rem.oved  by  the  end  of  the  week.  He 
has  thus  treated  44  patients  with  gratifying  results. 

WITHERBEE'g  REMOVABLE  SUTURE. 

O.  O.  Witherbee  inserts  a  figure-of-eight  suture  which  he  claims 
cannot  be  adjusted  with  sufficient  tension  to  stop  the  circulation  if  prop- 
erly inserted.  It  has  the  additional  advantage  of  being  removable,  and  con- 
sequently it  does  not  overburden  the  power  of  absorption  nor  does  it 
tend  to  cause  sloughing.  To  insure  proper  fixation  and  to  relieve  the  skin 
from  undue  pressure,  a  U-shaped  plate  is  employed  to  the  arms  of  which 
are  attached  the  sutures  after  they  emerge  from  the  skin.  Witherbee 
claims  that  four  silkworm  gut  sutures  thus  introduced  will  effectually  ap- 
proximate both  layers  of  Poupart's  ligament  with  the  external  and  in- 
ternal oblique,  the  transversalis  and  the  rectus  muscles,  if  necessary,  main- 
taining their  approximation  for  an  indefinite  period,  or,  at  least,  until 
firm  union  has  taken  place.  Witherbee  also  advises  leaving  the  cord  alone 
and  sparing  the  tissues  all  unnecessary  manipulation. 

REMOVABLE  CONTINUOUS  SUTURES. 

Charles  H.  Davison,  of  Chicago,  employs  a  suture  for  the  closure  of 
all  laparotomy  wounds  that  are  not  drained,  a  removable,  continuous, 
longitudinal,  silkworm  gut  suture,  which  approximates  each  layer.  Al- 
though the  suture  was  not  devised  especially  for  the  closure  of  hernial 
wounds,  yet  it  may  be  used  for  this  purpose  (Fig.  42).  The  suture  in  the 
fascia  of  the  abdominal  wall  is  fastened  by  terminal  bowknots  on  the  upper 
surface  of  the  fascia,  and  the  free  ends  of  the  suture  are  allowed  to  pro- 
trude from  the  wound.  The  bowknots  are  untied  by  traction  on  the  ex- 
posed ends,  and  the  suture  removed  at  the  completion  of  the  process  of 
healing. 


PLATE  XLIX. 

Ferguson's  Operation  for  Inguinal  Hernia. 
(Ochsner's  Clinical  Suro-ery.) 


OPERATIONS    FOR    INGUINAL    HERNIA  2/7 

The  technic  of  the  suture  of  the  wound  in  a  median  laparotomy  is  as 
follows:  All  hemorrhage  in  the  wound  in  the  abdominal  wall  is  stopped 
by  spong-e  pressure,  by  forcipressure  or  by  torsion ;  no  catgut  whatever  is 
used.  The  edges  of  the  peritoneum  are  caught  with  forceps,  and  are  held 
up.  away  from  the  intestine,  by  an  assistant,  and  the  peritoneum  is  approx- 
imated by  a  continuous  ringbone  suture.  The  suture  is  lightly  shirred  to 
take  up  all  the  slack,  and  the  ends  are  left  hanging  out  of  the  angles  of  the 
wound,  temporarily  held  out  of  the  way  by  snap  forceps.  In  a  median 
laparotomy  the  linea  alba  is  the  strong  layer  of  the  abdominal  wall,  and  if 
this  layer  be  fastened  securely  there  can  be  no  spreading-  of  the  wound. 
The  edges  must  be  accurately  approximated.  The  fat  must  be  cleaned 
away,  so  that  there  shall  be  no  interposition  of  tissue  between  the  edges 
of  the  fascia,  as  that  would  weaken  the  line  of  union  and  predispose  to 
ventral  hernia.  For  this  suture  a  perfect  strand  of  silkworm  gut,  soft  and 
pliable  from  recent  boiling,  is  selected.  A  small  reverse  bowknot  is  loosely 
tied  lo  or  12  cm.  from  the  end  of  the  strand.  The  edges  of  the  fascia  are 
caught  with  forceps  and  held  by  an  assistant.  The  suture  is  introduced  in 
a  firm  place  in  the  fascia  back  from  the  angle  of  the  wound  and  drawn  up 
to  the  knot,  and  the  fascia  is  approximated  by  a  continuous  herring-bone 
suture.  The  needle  perforations  in  the  fascia  are  placed  about  ^  cm. 
from  the  edge  and  i  cm.  apart. 

At  the  last  stitch  the  suture  is  shirred  up  tightly,  grasped  by  a  smooth 
(serrations  filed  off)  dissecting  forceps  at  its  exit  from  the  fascia,  held  by 
an  assistant,  and  another  reverse  bowknot  tied  below  the  point  of  the  for- 
ceps. In  tying  the  knot  around  the  forceps  the  strand  must  pass  under  the 
forceps,  and  the  loop  must  pass  up  from  below,  or  no  knot  will  result.  The 
greatest  care  must  be  used  not  to  crush  or  fray  the  silkworm  gut  with  the 
forceps  at  the  knot,  for  such  a  defect  might  cause  the  stiand  to  break  at 
that  point  at  the  time  of  removal.  As  the  bowknot  is  intended  only  to 
form  a  body  to  obstruct  the  passage  of  the  sutures  through  the  fascia,  it 
should  be  tied  loosely,  to  make  a  larger  obstruction,  and  to  facilitate  its 
untying  at  the  time  of  removal.  The  ends  of  the  tied  suture  must  not  be 
held  out  of  the  way  by  snap  forceps,  as  their  weight  might  untie  the  knots. 
The  linea  alba,  being  securely  fastened,  takes  all  the  tension  from  the  other 
layers,  and  the  unfastened  sutures  in  the  other  layers  do  not  tend  to  pull 
loose. 

The  skin  is  closed  by  the  Halsted  subcutaneous  stitch.  If  the  patient 
is  very  fat,  an  extra  running  suture  can  be  placed  to  approximate  the  fat 
and  to  avoid  a  dead  space.  If  the  wound  is  too  long  to  close  with  a  single 
silkworm  gut  strand,  it  is  closed  in  sections,  by  repeating  each  suture. 
Lateral  celiotomies  are  closed  by  suturing  each  layer  of  fascia  with  a  tied 
strand  of  silkworm  gut,  not  allowing  muscle  or  fat  to  be  included  in  the 
suture. 

SINGLE  TIER  SUTURE. 

J.  R.  Eastman  (Annals  of  Surgery,  Jan.,  1906)  describes  a  method 
for  closing  all  the  layers  with  a  single  tier  of  easilv  removable  non-buried 


278  OPERATIONS    FOR    INGUINAL    HERNIA 

sutures  which  coapt  all  the  layers  either  according  to  Bassini's  method  or 
the  method  devised  by  the  writer.  In  six  cases  operated  according-  to  this 
method  Eastman  used  a  heavy  Pagenstecher  celloidin  linen.  The  incis- 
ion is  carried  down  to  the  aponeurosis  of  the  internal  oblique  muscle,  so 
as  to  expose  both  the  external  and  internal  rings.  The  overlying  super- 
ficial tissues  should  be  wiped  with  gauze,  so  that  Poupart's  ligament  may 
be  exposed  freely.  After  reduction  of  its  contents  the  sac  should  be 
twisted  on  itself  as  advocated  by  C.  PL  Mayo.  The  suture,  bearing  a 
needle  on  each  end,  is  first  passed  through  Poupart's  ligament  from  with- 
out inward,  one  inch  from  its  free  margin.  It  is  then  passed  through  the 
outer  border  of  the  internal  oblique  and  transversalis  muscles  and  brought 
back  through  the  ligament  about  one-third  of  an  inch  nearer  its  margin 
than  the  first  point  of  passage.  The  needle  is  then  made  to  overlap  the 
free  margin  of  Poupart's  ligament  and  the  aponeurosis  of  the  external 
oblique  by  carrying  the  linen  through  in  the  form  of  a  simple  running 
mattress  suture. 

The  needle  is  next  passed  through  the  superficial  fascia,  fat  and  skin 
emerging  about  one-eighth  of  an  inch  from  the  skin  wound  margin  on 
the  side  opposite  Poupart's  ligament.  The  needle  on  the  tail  of  the  suture 
is  brought  up  through  the  subcutaneous  fat  and  skin  on  the  side  of  the 
ligament  when  traction  is  made  on  the  two  ends  of  the  suture.  No  kinks 
or  curls  remain,  and  the  suture  is  tied  as  a  simple  loop  which  may  be  drawn 
out  with  the  slightest  traction. 

The  method  is  said  to  be  applicable  in  practically  every  case  of  radical 
operation  for  inguinal  hernia  in  children.  In  small  hernias  in  adults  the 
simple  tier  method  is  applicable,  and  in  very  large  hernias,  with  a  wide 
separation  of  the  conjoined  tendon  and  Poupart's  ligament,  this  suture  is 
not  efficient. 

SILVER  WIRE  m  mGUINAL  CANAL. 

About  seven  years  ago  A.  M.  Phelps,  of  New  York,  conceived  the 
idea  of  introducing  silver  wire  into  the  inguinal  canal  in  cases  where  the 
hernia  was  unusually  large.  He  used  a  very  fine  wire  that  had  been  ster- 
ilized carefully,  then  immersed  in  carbolic  acid  and  passed  through  the 
flame  of  an  alcohol  lamp  just  before  using.  He  claimed  that  from  twenty- 
five  to  a  hundred  feet  of  wire  could  be  inserted  without  causing  any  dis- 
turbance, and  in  one  case  he  introduced  as  much  as  three  hundred  feet 
of  the  wire.     It  was  not  necessary  to  remove  the  wire  subsequently. 

ELECTRICITY  IN  HERNIA. 

In  August,  1899,  H.  Lane  reported  his  results  obtained  from  the  use 
of  electricity  for  the  cure  of  hernia.  He  introduced  a  needle  into  the 
inguinal  canal  and  passed  a  current  of  electricity  of  the  strength  of  twenty 
milliamperes  for  twenty  minutes.  A  truss  was  then  applied,  which  the 
patient  was  instructed  to  wear  for  two  months,  at  the  end  of  which  time 
a  cure  is  efifected. 


OPERATIONS    FOR    INGUINAL    HERXIA  2/9 

BICYCLING  m  HIENIA. 

Some  years  ago  Championniere  stated  that  bicycling  was  of  benefit 
in  the  treatment  of  hernia  because  it  tended  to  strengthen  the  abdominal 
muscles  and  to  improve  the  general  health.  The  use  of  the  bicycle  should 
be  begun  soon  after  the  patient  recovers  from  the  operation. 


CHAPTER  IV. 

THE  TYPIC  OR  ANATOMIC  (FERGUSONj  OPERATION. 

This  operation  was  devised  by  the  author  January,  1898,  presented  to 
the  profession  in  Ma}^,  1900,  at  a  meeting  of  the  American  Medical  Associa- 
tion, at  Columbus,  Ohio,  and  published  in  the  Journal  of  the  Association, 
July  I  St,  of  the  same  year.  *     - 

On  page  644,  ''Haiidhuch  der  praktischen  Chirurgie,"  by  Bergmann, 
Bruns  and  Mikulicz,  III  B.  L  T.,  appears  a  cut  illustrating  what  is  called 
Girard's  operation,  in  which  the  internal  oblique  muscle  is  sutured  to  Pou" 
part's  ligament.  In  this  particular,  and  in  that  the  spermatic  cord  is  not  dis- 
lodged, the  operation  resembles  the  typic  operation  of  the  writer.  The 
Girard  operation  was  first  published  in  the  October,  1900,  number  of  the 
Archives  Provinciale  de  Chirurgie.  It  would  not  be  necessary  to  refer  to 
what  has  been  erroneously  called  Girard's  operation,  were  it  not  that  errors 
of  omission  and  commission  on  the  part  of  certain  American  surgeons  have 
recently  manifested  themselves  at  discussions  on  the  subject  of  hernia. 

C.  Hoffman  {Centralhlatt  f.  Chirurgie,  October,  1903)  describes  an  op- 
eration which  embodies  the  principles  governing  the  typic  operation.  In  it 
the  sac,  the  transversalis  fascia,  the  internal  oblique  muscle,  and  the  aponeu- 
rosis of  the  external  oblique,  are  dealt  with  much  the  same  as  is  done  by  the 
writer,  only  differing  in  minor  matters  of  technic.  A.  J.  Ochsner  (Central- 
hkbtt  f.  Chirurgie,  April  2,  1904)  very  kindly  pointed  out  to  the  German 
profession  that  this  is  Ferguson's  operation,  published  four  years  previous 
to  Hoffman's  article,  which  was  no  doubt  inadvertently  overlooked  by  him.. 

While  the  anatomic  principles  on  which  the  typic  operation  is  founded 
are  as  unassailable  and  as  fixed  as  is  the  anatomy  of  the  part  itself,  the  tech- 
nic, however,  may  vary  materially  according  to  the  conditions  encountered. 
Since  the  presentation  of  this  operation  to  the  profession,  the  writer  has  not 
found  it  necessary  to  make  any  material  improvements  or  modifications.  A 
few  new  aids  to  its  performance  will  be  offered  in  the  text,  and  the  number 
of  illustrations  for  its  demonstration  is  lessened. 

The  aim  of  the  operative  procedure  is  to  imitate  nature  by  fixing  the 
various  structures  in  their  proper  relationship,  one  to  the  other.  Even  when 
the  anatomy  is  very  defective  (congenital  or  acquired),  the  surgeon  who 
possesses  a  practical  knowledge  of  the  normal  parts  in  the  inguinal  region, 
and  who  is  an  experienced  operator,  should  have  little  difficulty  in  differen- 
tiating one  structure  from  another,  and  executing  a  rational  procedure  which 
takes  into  consideration  the  function  of  each  anatomic  entity  in  this  area. 

It  is  admitted  that  over  six  per  cent,  of  the  recurrences  in  Bassini's  op- 
eration occur  at  the  upper  angle  of  the  wound.    Why?    Because  the  cord  is 


THE    TYPIC    OR    ANATOMIC     (fERGUSON)     OPERATION  28I 

transplanted  there  and  the  internal  ring  does  not  receive  full  protection. 
This  in  itself  is  a  sufficient  reason  for  discarding  that  operation,  especially 
when  another  (the  writer's)  can  be  selected,  which  is  easier  of  execution, 
involves  less  manipulation  of  the  structures,  is  anatomically  and  physiologi- 
cally perfect,  and,  as  far  as  its  author  knows,  is  without  recurrences.  Hal- 
sted  says :  "It  was  well  worthy  of  note  that  all  of  the  cases  treated  in  this 
manner  (cord  undisturbed)  remained  cured."  The  writer,  prior  to  1898, 
observed  that  recurrences  at  the  upper  end  of  the  wound  were  frequent,  and 
in  1898  discovered  a  deficient  attachment  at  Poupart's  ligament  of  the  in- 
ternal oblique  muscle.  These  observations  led  to  the  evolution  of  his  typic 
operation. 

At  the  writer's  request,  his  assistant,  who  was  also  teaching  surgical 
anatomy,  made  fifty  dissections  and  some  experiments  on  the  cadaver.  These 
supported  the  author's  claim  regarding  the  congenital  deficient  origin  of  the 
internal  oblique  muscle  at  Poupart's  ligament.  Inasmuch  as  every  opera- 
tion for  the  cure  of  hernia  is  a  dissection  on  the  living,  accurate  measure- 
ments made  while  operating  will  verify  the  above,  which  has  been  done  by 
myself  in  almost  every  case  for  the  last  eight  years. 

Before  proceeding  with  the  description  of  the  Ferguson  operation,  let 
us  consider  briefly  some  points  in  the  etiology  of  hernia  that  are  essential 
to  a  correct  understanding  of  this  operation. 

Let  the  passive  intra-abdominal  pressure  predisposing  to  rupture  be 
what  it  may — elongated  mesentery,  large  omentum,  or  what  not — we  cannot 
hope  to  lessen  it  to  any  great  extent;  but  we  can  strengthen  the  abdominal 
wall  at  the  seat  of  rupture  in  such  a  manner  as  not  only  to  withstand  the 
passive,  but  also  resist  the  active  pressure  within  the  abdomen  while  strain- 
ing, lifting  etc. 

The  etiology  of  inguinal  hernia  is  still  a  problem.  While  it  is  correct 
to  say  that  the  congenital  oblique  inguinal  hernia  is  usually  due  to  the  non- 
closure of  the  funicular  process  at  the  internal  ring,  it  does  not  explain  why 
this  process  remains  patulous  in  some  men  and  why  it  closes  in  others. 
When  we  consider  the  physiologic  process  by  which  the  testicle  descends 
from  the  abdominal  cavity  to  the  scrotum,  it'  is  not  surprising  that  oblique 
inguinal  hernia  is  five  times  more  common  in  the  male  than  in  the  female, 
and  that  over  three-fourths  of  all  abdominal  hernias  are  of  this  kind.  Im- 
perfect closure  of  the  internal  ring  is  common.  It  is  occasionally  open,  and 
no  hernia  protrudes ;  then  it  must  be  that  the  bowels  and  omentum  are  well 
suspended,  and  do  not  press  unduly  on  the  abdominal  wall  or  valvular  ar- 
rangement of  the  structures  at  the  internal  ring  and  along  the  canal,  which 
is  normal,  and  Cooper's  fascia  is  strong  and  firm.  In  a  perfect  anatomic 
subject  the  internal  ring  is  so  smoothly  closed  over  that  an  infundibular 
process  of  the  peritoneum  is  very  insignificant,  or  not  at  all  perceptible ;  the 
valve  formation  of  the  internal  ring  and  canal  absolutely  prevents  a  giving 
way  at  the  internal  ring,  for  the  more  the  intra-abdominal  pressure  increases, 
the  tighter  the  valve  closes ;  provided,  however,  that  a  normal  muscular  and 
aponeurotic  support  is  protecting  it  external  to  the  transversalis  fascia. 

The  two  main  structures  that  stand  on  guard  to  protect  the  internal 


282 


THE    TYPIC    OR    ANATOMIC     (FERGUSON )     OPERATION 


1, 


1^ 


ring-  are  the  internal  oblique  muscle  and  the  aponeurosis  of  the  external 
'  oblique,  the  former  being  the  active  agent  ready  to  contract  instantly,  the 
moment  the  ring  is  subjected  to  a  sudden  increase  of  intra-abdominal  pres- 
sure, as  in  running,  jumping,  lifting,  etc.  The  fact  is  that  in  oblique  hernia 
the  internal  ring  receives  no  substantial  protection  from  the  internal  oblique 
muscle,  for  the  reason  that  it  is  not  attached  to  the  internal  aspect  of  Pou- 
part's  ligament  sufficiently  low  down,  and  as  it  passes  downward  and  in- 
ward from  its  deficient  origin,  it  passes  above  the  center  of  the  internal 
ring;  or  the  lower  border  of  the  muscle  which  forms  the  cremaster  is  not 
held  down  sufficiently  to  prevent  a  protrusion  of  the  abdominal  contents. 

Indeed,  the  origin  of  this  muscle  may  be  entirely  deficient  at  Poupart's 
ligament,  and  this  affords  an  opportunity  for  a  sausage-shaped  protrusion 
of  a  hernial  nature  in  the  groin.  Is  it  not  probable  that  this  congenital  de- 
fect of  the  internal  oblique  muscle  is  accountable  for  the  non- closure  of  the 
internal  ring?  If  the  internal  ring  is  protected  auring  the  descent  of  the  tes- 
ticle, one  would  suppose  that  the  muscular  tonicity  v^^ould  soon  close  the 
course  the  testicle  had  taken  behind  the  internal  oblique  muscle. 

The  key  to  the  radical  cure  of  oblique  ingumal  hernia  is  to  suture  the 
1  internal  oblique  muscle  and  its  tendon  to  the  inner  aspect  of  Poupart's  liga- 
ment, as  low  down  as  possible,  without  undue  tension,  after  having  ablated 
the  sac  and  strengthened  the  internal  ring  with  a  few  stitches  above  the 
'root  of  the  cord.  Any  operation  for  the  cure  of  hernia  that  diverts  the 
cord  from  its  natural  course  favors  return,  endangers  the  testicle  and  is 
empirical,  and  empiricism  is  the  very  thing  that  thinking  men  through  all 
the  centuries  have  been  trying  to  avoid.  If  all  our  work  were  done  on  the 
plan  of  expediency,  the  search  for  the  truth  in  the  science  of  surgery  would 
lose  its  charm,  and  the  art  of  imitating  nature  would  lose  its  beauty. 

In  the  anatomic  or  typic  operation  the  sac  is  tied  off.  Why?  To  re- 
store the  rotundity  of  the  peritoneum.  The  transversalis  fascia  is  sutured 
nicely  around  the  root  of  the  cord  Why?  In  order  to  obliterate  a  patho- 
logic infundibuliform  process,  and  to  make  a  new  internal  ring. 

The  internal  oblique  muscle  is  sutured  to  Poupart's  ligament  at  least 
two-thirds  the  way  down,  which  is  the  usual  attachment  found  in  the  female. 
Why?  That  a  congenital  defect  may  be  rectified,  and  the  muscle  may  be 
allowed  an  opportunity  to  protect  the  internal  ring;  and  the  aponeurosis  of 
the  external  muscle  is  then  sutured  and  the  skin  coapted,  for  the  reason  that 
the}'  may  occupy  their  normal  place  in  this  region. 

It  will  be  noted  that  no  step  is  taken  without  a  valid  anatomic  reason. 
When  the  hernia  is  a  direct  one,  or  when  the  conjoined  tendon  is  deficient 
or  absent,  an  additional  procedure  is  required,  and  that  is  to  split  the  sheath 
of  the  rectus  muscle,  and  sew  it  (rectus  muscle)  over  to  Poupart's  ligament, 
across  the  weak  point.  If,  however,  the  entire  inguinal  area  is  deficient, 
thinned  out,  atrophied,  or  degenerated,  the  writer  has  not  hesitated  to  trans- 
plant a  portion  of  the  sartorius  muscle  to  this  region  as  well.      ^      <*■• 

Operation. — After  preparation  begin  the  incision  over  Poupart's  liga- 
ment, one  and  a  half  inches  below  the  anterior  superior  spinous  process  of 
the  ilium;  extend  it  inward  and  downward  in  a  curved  (or  straight)   man- 


7 


THE    TYPIC    or"  anatomic     (fERGL'SON)     OPERATION  283 

ner,  circumventing  the  internal  abdominal  ring,  and  terminate  it  over  the 
conjoined  tendon  near  the  pubic  bone.  Cut  carefully  backward  vi^ith  a  very 
sharp  knife  and  expose  the  vessels.  Pick  them  up  with  forceps  before  sev- 
ering them,  thus  preventing  blood-staining  of  the  tissues.  Having  passed 
through  the  skin,  two  layers  of  superficial  fascia,  the  fat  between  them  and 
the  superficial  epigastric  vessels  down  to  the  aponeurosis  of  the  external 
oblique  muscle,  it  will  be  noticed  that  it  is  not  necessary  to  cut  the  super- 
ficial circumflex  iliac,  nor  the  superficial  pudic  vessels.  Take  a  pledget  of 
gauze,  and  with  it  turn  the  flap  of  skin,  subjacent  fat  and  fascia  downward 
and  outward  over  the  thigh.  This  procedure  brings  into  view  the  aponeu- 
rosis of  the  external  oblique  muscle,  the  external  abdominal  ring,  with  its 
pillars  and  intercolumnar  fascia,  the  hernial  sac,  if  it  has  descended  through 
the  external  ring,  the  external  surface  of  Poupart's  ligament,  the  under 
surface  of  the  flap  covered  by  the  deep  layer  of  superficial  fascia,  and  the 
superficial  vessels. 

Next  cut  through  the  external  abdominal  ring  and  the  intercolumnar 
fascia;  separate  the  longitudinal  fibers  of  the  aponeurosis  of  the  external 
oblique  muscle  directly  over  the  inguinal  canal,  beyond  the  internal  ring, 
over  the  surface  of  the  internal  abdominal  oblique  mmscle.  Delicate  trans- 
verse fibers  are  encountered  and  severed.  Retract  the  two  flaps  of  the 
aponeurosis  of  the  external  oblique  muscle  to  eacli  side,  thus  bringing  into 
view  the  deep  structures,  viz. :  The  contents  of  the  inguinal  canal,  the  whole 
sac  with  its  adhesions,  the  spermatic  cord,  ilio-inguinal  nerve,  internal  ab-- 
dominal  ring  usually  enlarged,  frequently  an  accumulation  of  subserous  fat, 
the  cremasteric  m.uscle,  conjoined  tendon,  internal  oblique  muscle,  and  its 
deficient  origin  at  Poupart's  ligament,  transversalis  fascia,  and  the  internal 
surface  of  Poupart's  ligament.     (Fig.  43.) 

The  author  considers  the  congenitally  deficient  origin  (Fig.  43)  of  the 
internal  oblique  and  transversalis  muscles  one  of  the  niost  frequent  and  im- 
portant causes  of  oblique  inguinal  hernia.  Inspect  these  structures  carefulh,, 
and  determine  whether  the  operation  is  to  be  typic  or  atyplc.  When  the 
structures  are  well-defined  and  not  too  much  weakened  by  pressure  atrophy, 
a  typical  operation  can  be  proceeded  with. 

At  this  stage  of  the  operation  deal  vvith  the  sac  and  its  contents  :  The 
cord,  cremaster  muscle,  and  subserous  lipomata. 

The  sac  is  always  opened  (Fig.  44)  preferably  at  its  neck,  at  its  junc- 
tion w4th  the  general  peritoneum,  and  then  carefully  dissected  from  the  cord 
and  internal  ring,  from  above  downward,  its  contents  inspected  and  dealt 
with,  and  the  sac  is  ligated  high  up,  or  sometimes  sutured,  or  an  internal  purse- 
string  thrown  around  it.  If  the  sac  is  of  congenital  origin,  divide  it  in  two, 
the  distal  half  to  form  a  tunic  for  the  testicle,  and  the  proximal  to  be  treated 
as  above  mentioned. 

When  omentum  is  found  within  the  sac  and  is  adherent  to  it,  it  is  with- 
drawn, tied  cii  masse,  cut  off,  the  stump  is  covered  with  its  own  peritoneum, 
or  rolled  beneath  and  within  a  fold  of  omentum,  and  there  held  by  a  stitch 
or  two  of  fine  chromic  catgut. 

The  writer  has,  very  many  times,  employed  Downes'  electro-thermic- 


284  THE    TYPIC    OR    ANATOAIIC     (FERGUSON)     OPERATION 

hemostat  clamps  for  the  removal  of  omentum,  and  inclines  to  the  belief  that 
they  are  safer  than  the  ligature.  When  the  omentum  is  redundant,  or  hyper- 
trophied,  its  amputation  decreases  intra-abdominal  pressure  and  lessens  the 
tendency  to  a  return  of  the  hernia.  If  the  omentum  is  not  adherent  it  is  us- 
ually not  necessary  to  remove  any  portion  of  it. 

When  the  sac  is  opened  it  is  frequently  found  advantageous  to  place  the 
patient  in  jjie  Trendelenburg  position  to  prevent  protrusion  of  and  injury  to 
the  intestines  and  omentum,  and  it  also  aids  in  the  closure  of  the  perito- 
neum, whether  by  ligature  or  suture. 

The  transplantation  of  the  stump  of  the  sac  high  up  underneath  the  deep 
muscles,  or  twisting  it  and  suturing  it  at  the  internal  ring,  has  nothing  special 
to  recommend  it.     It  must  be  remembered  that  when  a  new  internal  ring  is         » 
made  the  stump  of  the  sac  is  buried  beneath  the  transversalis  fascia,  which  ';■ '^'''^/^ 
must  protrude  it  into  the  peritoneal  cavity,  and  at  its  site  a  convexity  is  ob- 
tained. 

The  appendix  should  always  be  brought  out  and  inspected.  If  by  ap- 
pearance, or  feel,  or  the  history  of  the  case,  disease  of  it  is  at  all  suspected, 
it  had  better  be  removed.  When  the  patient  is  a  female,  the  condition  and 
position  of  the  uterus  and  ovaries  may  be  palpated,  and  any  surgical  inter- 
vention that  may  be  deemed  necessary  can  be  carried  out  through  an  en- 
larged hernial  incision. 

When  the  patient  has  also  given  evidence  of  stomach,  gall  bladder,  in- 
testina^l  or  other  surgical  intra-abdominal  disease,  the  writer  has  not  hesi- 
tated to  enlarge  the  opening,  pass  in  the  hand  and  carefully  explore  the  ab- 
dominal organs,  with  great  satisfaction  to  himself  and  oftentimes  with  bene- 
fit to  the  patient.  Gallstones,  carcinoma  of  the  sigmoid,  uterine  displace- 
ments, fibroids  and  ovarian  cysts  have  been  detected  in  this  manner,  and 
been  treated  surgically  there  and  then. 

In  order  to  adm.it  the  hand  and  forearm  through  this  opening  it  is 
necessary  to  make  ample  room  by  severing  the  attachment  at  Pottpart's 
ligament,  of  the  internal  oblique  and  transversalis  muscles,  and  extending 
the  opening  in  the  sac  upward  through  the  fascia  and  peritoneum ;  or  when 
the  conjoined  tendon  is  deficient  there  is  an  indication  to  open  the  sheath 
of  the  rectus  muscle  in  order  to  deal  properly  with  the  rupture,  then  it  is 
preferable  to  extend  the  opening  in  this  direction,  and  on  reaching  the  bor- 
der of  the  rectus  muscle,  open  its  sheath  and  extend  the  opening  to  the 
pubic  bone ;  then  cut  through  the  sheath  of  the  rectus  transversely  to  the 
linea  alba.  The  remaining  structures,  the  peritoneum  and  muscular  fibers 
of  the  muscle,  will  stretch,  while  the  transversalis  fascia  and  sparse  fibrous 
covering  on  the  posterior  surface  of  the  muscle  yield  to  a  little  force. 

While  exploration  of  the  abdomen  through  the  groin  is  a  subject  some- 
what irrelevant  to  this  subject,  still  the  writer  feels  that  the  value  of  the 
procedure  in  connection  with  hernia  patients  may,  in  a  measure,  justify  him 
in  deviating  from  the  subject  proper,  craving  the  reader's  indulgence. 

The  cord  is  not  disturbed.  The  writer  has  never  been  satisfied  with 
the  raising  and  transplantation  of  the  cord.  In  more  cases  than  have  been 
recorded  the  testicle  has  come  to  grief  by  this  unnecessary  procedure.    Tear- 


PLATE  L. 

Ferguson's  Operation  for  Femoral  "Hernia. 
I.  Falciform  process.     2.  External  oblique.     3.  Poupart's  lig.     4.  Gim- 
bernat's  lig. 


THE    TYPIC    OR    ANATOMIC     ( FERGUSON)     OPERATION  28/ 

ing  the  cord  out  of  its  bed  is  without  any  anatomic  reason  to  recommend  it ; 
any  physiologic  act  to  suggest  it ;  any  etiologic  factor  in  hernia,  congenital 
or  acquired,  to  indicate  it ;  or  brilliant  surgical  results  to  justify  its  continu- 
ance.    Let  the  cord  alone,  especially  the  vas  deferens,  for  it  is  the  sacred        ^         -l 
highway  along  which   travel   the  vital  elements   indispensable  to  the   per-     r\/<-CCi^  ^ 
petuity  of  our  race. 

The  veins  of  the  cord  should  not  be  disturbed.  If  a  variocele  compli- 
cates the  hernia,  deal  with  it  in  the  usual  way,  but  do  not  ablate  the  veins  in 
the  canal,  for  that  endangers  the  testicle.  When  the  veins  were  not  ablated, 
the  writer  has  not  seen  a  hydrocele  or  an  epididymitis  follow. 

The  cremaster  muscle  is  allowed  to  hug  the  cord  and  is  reattached  to 
the  internal  oblique  muscle,  for  in  this,  its  normal  position,  it  is  afforded  an 
opportunity  to  resume  its  double  function  of  (a)  holding  down  the  muscle 
from  which  it  originally  received  its  muscular  fibers,  and  (b)  by  its  con- 
traction aid  in  emptying  out  the  valveless  veins  in  the  cord.  No  part  of 
the  muscle  should  be  removed,  but  its  redundancy  is  taken  up  with  the 
suturing  of  the  transversalis  fascia  and  internal  oblique. 

An  abnormal  quantity  of  subserous  adipose  tissue  is  sometimes  depos- 
ited around  the  sac  and  cord  and  along  Poupart's  ligament.  This  is  an 
etiologic  factor  in  hernia,  and  if  not  removed  tends  to  cause  a  return  of  the 
hernia.  A  systematic  search  should  be  made  for  fatty  aggregations  and  the 
same  removed.  (See  "Adipose  Tissue  an  Etiologic  Factor  in  Hernia,"  Ma}-,  ^7/vjZ^<r4>^<A</ 
1899,  Illinois  Medical  Journal,  by  the  author.)  .._^.,..-'^^^  / 

The  transversalis  fascia  forms  the  internal  ring. /'In  hernia  its  fibers  *— ■■ 

have  become  more  or  less  stretched  above  and  around  the  cord.     The  ring,  I,  / 

in  consequence,  is  abnormally  large  and  the  fascia  bulges.     To  rectify  this  f  ^   W^iVt '^ 
condition  take  up  the  slack  in  the  fascia  and  make  an  accurately  fitting  ring  ^  tiky^  '^y^^^Ti 
for  the  cord  %  means  of  a  suture,  interrupted  or  continuous.     The  writer     t^(*  \-~t^^^^ 
usually  takes  up  the  slack  .in  this  fascia  with  the  same  sutures  that  sew  the     "^'^  Hf/vwAC.  <t,' 
internal  oblique  muscle  to  Poupart's  ligament.     (Fig.  45.)     Do  not  injure 
the  deep  epigastric  vessels,  nor  pass  the  needle  too  deeply  in  the  direction 
of  the  large  iliac  vessels. 

Suture  the  internal  oblic[ue  and  transversalis  muscles   (Fig.  46)   to  tne  i 

internal  aspect  of  Poupart's  ligament,  and  restore  their  normal  origin.     If  i^i'^lh^i.^L 
you  choose,  take  up  the  slack  of  the  transversalis  fascia  and  the  crema.stex^^^^^^^'^J^'f'-^^,^ 
muscle  with  the  same  suture.      (Fig.  48.)     The  suturing  is  extended  fully  /■«  oJ^Ji~e-^  ^ 
two-thirds  down  along  Poupart's  ligament,  which  is  the  normal  origin  of  C^\^  /  / 

this  muscle  in  the  female.     Take  care  not  to  split  Poupart's  ligament  by 
grasping  the  same  longitudinal  fibers  with  the  needle  each  time.     It  is  sur- 
prising how  easily  these  structures   come  together  without  the  least   dis- 
cernible tension  when  the  muscles  are  well  liberated,  and  it  is  gratifying  to  J^     ALvvr^ 
observe  how  perfectly  they  cover  and  protect  the  internal  abdominal  ring.     '  ''^/^O^yy^-' 

(Fig.  45-)  ■  ■'    ■      ^■■>H^^i'  OH 

If  the  conjoined  tendon  is  deficient  or  absent,  or  if  a  direct  hernia  co- 
exists, the  sheath  of  the  rectus  muscle  is  opened  freely  down  to  the  pubic 
bone  (Bloodgood,  Fig.  47),  and  the  muscle  brought  across  the  weak  point 
to  Poupart's  ligament.     The  writer  has  observed  a  few  direct  hernias  occur 


288  THE    TYPIC     OR    ANATOMIC     (FERGUSON)     OPERATION 

after  the  cure,  by  operation,  of  an  oblique  inguinal  hernia.  In  these  cases 
the  conjoined  tendon  was  deficient  and  the  rectus  muscle  was  not  utilized  at 
the  primary  operation. 

The  external  edges  of  the  aponeurosis  of  the  external  oblique  muscle 
are  brought  together  in  lateral  folds  (Fig.  49)  or  by  overlapping,  thus  re- 
storing the  external  abdominal  ring.  (Fig.  45.)  In  bringing  the  skin 
flap  into  normal  position,  be  sure  to  coapt  all  its  structure,  like-to-like,  espe- 
cially the  layers  of  the  superficial  fascia. 

The  different  structures  in  the  abdominal  wall  are  placed  in  their  nor- 
mal relationship.  The  tying  of  the  sac  restores  the  normal  rotundity  of 
the  peritoneum.  The  suturing  of  the  transversalis  fascia,  forming  a  new  | 
internal  ring,  at  the  same  time  obliterates  the  hernial  infundibuliform  pro-  ' 
cess.  Sewing  the  internal  oblique  and  transversalis  muscle  to  Poupart's 
ligament  secures  a  normal  origm  for  them,  and  they  then  form  a  perfect 
protection  of  the  internal  ring,  cord  and  canal.  (Fig.  43.)  The  lateral  or 
overlapping  suturing  of  the  separated  fibers  of  the  aponeurosis  of  the  ex- 
ternal oblique  protects  the  underlying  muscles  and  cord,  while  the  skin  flaps 
covers  all.  The  lines  of  the  sutures  are  not  opposite  each  other,  thus  se- 
curing an  overlapping  of  the  weak  parts  (line  of  repair)  by  normal  tissues. 

The  curved  incision  has  advantages  for  purposes  of  demonstration.  The 
hernial  area  is  uncovered  as  in  no  other  way,  thus  affording  an  accurate  ob- 
servation of  structural  relationship,  etiologic  factors  and  pathologic  condi- 
tions. There  is  less  tendency  of  skin  infection  extending  to  the  deeper 
structures. 

In  cases  of  old  scrotal  hernias  the  large  space  from  which  the  sac 
was  dissected  is  drained  with  several  strands  of  silkworm  gut  until  the  first 
dressing  is  changed. 

We  are  gradually  coming  to  the  conclusion  that  after  operation  pa- 
tients are  usually  kept  in  bed  for  too  long  a  time,  but  the  writer  still  en- 
joins three  weeks  in  the  horizontal  position  after  an  operation  for  the  radi- 
cal cure  of  hernia.  A  bandage  and  pad  are  worn  for  three  months  there- 
after, but  no  truss. 

For  ligatures  and  sutures,  Nos.  00,  o,  and  i  of  chromic  catgut  are  used 
throughout  the  operation ;  No.  i  to  tie  off  the  sac,  and  the  other  sizes  for 
the  coaptation  of  the  remaining  structures.  The  author  believes  that  the 
large-sized  catgut  used  by  other  operators  in  miany  instances  is  accountable 
for  suppuration  and  failure.  The  catgut  should  not  be  absorbed  short  of 
about  two  or  three  weeks. 

Of  all  the  methods  of  operating  the  author  has  employed,  the  anatomic 
is  the  simplest  and  easiest  to  execute.  The  results  are  all  that  could  be 
wished,  there  being  no  known  return  in  2,500  patients  operated  on  by  differ- 
ent sursreons. 


CHAPTER  V. 

RADICAL  CURE  OF  FEMORAL  HERNIA. 

The  radical  cure  of  femoral  hernia  has  not  engrossed  the  attention  of 
surgeons  to  the  same  extent  as  Has  that  of  the  inguinal  variety.  One  rea- 
son for  this  may  be  the  comparative  infrequency  of  femoral  hernia,  and  an- 
other may  be  found  in  the  belief  that  the  operation  is  more  difficult  to  per- 
form than  is  that  for  inguinal  hernia.  However,  a  number  of  operations 
have  been  devised  and  some  of  them  have  been  used  extensively  and  with 
excellent  results. 

Sir  Astley  Cooper  dissected  out  the  sac  and  closed  the  femoral  ring  se- 
curely by  means  of  sutures.  Mitchell  Banks  placed  a  ligature  around  the 
neck  of  the  sac,  and  then  cut  it  away,  but  made  no  attempt  to  close  the  canal. 

Ball  and  Houston  twisted  the  sac,  ligated  it  at  its  neck,  cut  it  off,  and 
closed  the  femoral  canal  with  sutures.  Barker  removes  the  sac  after  having 
ligated  it  at  its  neck.  The  stump  of  the  sac  is  then  pushed  under  the  femoral 
arch  and  the  canal  is  closed  with  sutures  which  grasp  the  pubic  portion  of 
the  fascia  lata  and  Poupart's  ligament. 

Marcy  cuts  oft'  the  s?.c  below  a  ligature  and  closes  the  canal  bv  sutures 
of  kangaroo  tendon.  AIcBurney  used  the  open  method,  the  sac  being  li- 
gated, cut  away,  and  the  wound  packed  with  iodoform  gauze.  ^lacewen,  of 
Glasgow,  employed  the  sac  as  a  plug,  much  in  the  same  manner  as  in  his 
operation  for  inguinal  hernia,  the  plug  forming  a  prominence  on  the  in- 
ternal aspect  of  the  peritoneal  cavity.  He  completed  the  operation  by 
stitching  the  falciform  process  to  Gimbernat's  ligament,  thus  restoring  the 
normal  valve-like  condition  of  these  parts.  Harvey  Gushing  closes  the  fem- 
oral ring  with  a  quilted  suture,  fastening  the  pubic  portion  of  the  fascia  lata 
covering  the  pectineus  muscle  to  Poupart's  ligament  before  closing  the 
saphenous  opening  according  to  Macewen's  method. 

In  my  operation  I  close  the  canal  with  three  inversion  sutures,  seizing 
hold  of  the  fascia  and  pectineus  muscle,  close  to  the  pubic  bone,  and  then 
grasping  Poupart's  ligament  from  above  downward.  (Fig.  50.)  These 
sutures,  when  tied,  cause  the  falciform  process  to  recede  behind  them  into 
the  canal  on  a  level  with  the  deep  crural  arch.  When  the  sac  is  small  and 
slender,  and  if  Poupart's  ligament  and  the  falciform  process  cannot  be 
brought  down  sufficiently  close  to  the  pectineal  fascia,  to  obliterate  the  fem- 
oral canal  effectually,  there  need  be  no  hesitation  in  raising  a  flap  from 
the  pectineus  muscle,  or  from  the  periosteum  of  the  pubic  bone,  and  sewin^ 
either  with  quilt  sutures  to  the  deep  crural  arch,  fastening  the  falciform  pro- 
cess beneath  it,  as  already  described. 

It  is  rather  difficult  to  comprehend  the  reason  for  cutting  off  the  sac, 
which  can  be  utilized  as  a  plug  to  the  best  advantage.    The  sac  consists  of 


290  RADICAL     CURE     OF     FEMORAL     IIERXLA 

fibrous  tissue,  whereas  when  a  mass  of  muscle  is  raised  to  form  a  plug,  it 
means  that  this  muscle  must  be  converted  into  fibrous  material.  If  the  sac 
is  very  small  or  the  canal  very  large,  I  believe  that  Cheyne's  flap  would  aid 
materially  in  preventing  a  relapse.    I  have  not  seen  this  condition. 

Josef  Fabricius  recommends  ligating  the  sac  and  then  cutting  it  ofif.  He 
exposes  the  crural  canal  freely  by  division  of  the  superficial  layer  of  deep 
fascia  and  the  removal  of  loose  cellular  tissue.  The  internal  attachment  of 
Poupart's  ligament  is  divided,  thus  relaxing  it,  and  it  is  then  sutured  to  the 
pectineal  fascia,  the  origin  of  the  pectineus  muscle,  and  to  the  periosteum 
of  the  horizontal  ramus  of  the  pubic  bone.  (Figs.  51  and  52.)  The  first 
stitch  is  applied  next  to  the  femoral  vessels,  being  drawn  by  a  blunt  hook 
toward  the  ilio-pectineal  eminence.  This  stitch  prevents  these  vessels  from 
returning  to  their  normal  position.  Fabricius  also  recommends  stitching 
the  superficial  layer  of  the  deep  fascia  to  the  pectineal  fascia  along  the 
femoral  vein. 

The  objections  to  this  operation  are  that  it  necessitates  the  division  of 
Poupart's  ligament,  and  the  fact  that  so  extensive  an  operation  is  not  at 
all  necessary  to  produce  a  radical  cure  of  the  hernia. 

Bassini's  method  of  operating  on  femoral  hernia  embraces  the  re- 
moval of  the  sac  and  then  putting  m  two  rows  of  sutures,  one  fastening 
Poupart's  ligament  to  the  pectineal  fascia  for  the  purpose  of  closing  the 
femoral  canal,  and  the  other  suture  securing  the  falciform  ligament  to 
the  pectineal  fascia  and  muscle. 

BALDWIN'S  OPERATION. 

For  some  years  past  Baldwin  has  made  use  of  an  operation  which 
in  his  hands  has  proven  uniformly  successful  in  about  twenty  cases.  He 
describes  his  method    [Lancet,  July  21,    1906)    as   follows: 

"A  curved  incision  about  1J2  or  2  inches  long  is  made  over  the 
saphenous  opening.  The  sac  is  isolated  and  more  or  less  cleared  of  fat. 
If  not  already  back,  the  hernia  is  reduced.  A  slightly  curved  hernia 
director  is  now  'introduced  up  the  crural  canal  in  front  of  the  sac  and 
when  its  point  is  behind  Poupart's  ligament  it  is  moved  laterally  so  as  for 
a  short  distance  to  strip  off  the  peritoneum  from  the  posterior  surface  of 
the  transversalis  fascia.  The  point  of  the  director  is  now  pushed  farther 
upward  and  tilted  forward  so  as  to  make  the  aponeurosis  of  the  external 
oblic[ue  muscle  project  about  half  an  inch  above  Poupart's  ligament.  A 
small  transverse  incision  is  then  made  through  the  aponeurosis,  parallel 
to  its  fibers,  on  to  the  point  of  the  director,  which  is  now  pushed  up  through 
the  opening.  The  latter  is  only  just  large  enough  to  allow  of  this  being 
done.  A  sinus  forceps,  Spencer  Wells  forceps,  or  small  nasal  polypus  for- 
ceps— the  last,  being  slightly  curved,  is  more  convenient — is  now  intro- 
duced through  the  opening,  passed  behind  Poupart's  ligament,  and  made 
to  project  from  the  saphenous  opening;  as  this  is  done  the  director  is 
withdrawn ;  in  its  descent  it  guides  the  forceps  and  prevents  it  from  catch- 
ing. The  fundus  of  the  sac  is  now  seized  by  the  forceps,  which  is  com- 
pletely withdrawn,  dragging  the  sac  out  through  the  opening  in   the   ex- 


PLATE  LI. 
Fabricius'  Operation  for  Femoral  Hernia.  (Fowler). 


RADICAL     CCRE     OF     FEMOR^XL     HERNIA  293 

ternal  oblique  aponeurosis.  The  sac  is  pulled  out  as  much  as  possible 
and  ligated  at  the  top  of  its  neck.  By  this  maneuver  no  pouch  is  left  in 
which  recurrence  may  take  place.  A  suture  is  then  passed  throug-h  the 
fundus  of  the  sac,  the  suture  is  drawn  through  to  its  middle  and  then 
tied,  thus  leaving  two  free  ends  of  equal  length,  or  this  may  be  done  be- 
fore the  sac  is  pulled  up  through  the  opening  in  Poupart's  ligament,  the 
thread  being  seized  by  the  forceps  and  used  to  pull  up  the  sac.  If  the 
sac  is  large,  however,  the  thread  may  tear  out  and  time  be  lost.  One  end 
is  threaded  in  a  strong  curved  needle,  one  which  will  not  rotate  in  the 
forceps  which  grasps  it.  The  needle  is  now  passed  backward  and  for- 
ward through  the  sac  several  times,  starting  at  the  fundus  and  finishing  at 
the  neck,  as  described  by  Macewen,  for  puckering  the  sac.  The  needle 
is  grasped  in  forceps,  or  a  needle  on  a  handle  may  be  used,  and  its  point 
is  passed  through  the  hole  above  Poupart's  ligament,  through  the  neck  of 
the  sac  down  to  the  transverse  ramus  of  the  pubes,  then  by  a  turn  of  the 
wrist  the  point  is  made  to  slide  forward  across  the  pubic  bone,  as  close 
to  it  as  possible,  then  to  pierce  the  pectineus  muscle  and  to  appear  through 
the  inner  part  of  the  saphenous  opening.  The  needle  is  pulled  through, 
bringing  its  thread  with  it.  By  drawing  on  the  thread  and  by  tucking 
the  sac  back  again  through  the  hole  above  Poupart's  ligament  by  means  of 
a  stout  probe  or  similar  blunt  instrument,  the  sac  disappears  from  view 
and  comes  to  rest  in  a  puckered-up  condition  behind  the  transversalis  fascia 
and  at  the  top  of  the  crural  canal,  which  it  effectually  roofs  in.  By  this 
time  the  other  end  of  the  thread  is  hanging  out  of  the  opening  above  Pou- 
part's ligament.  It  is  tied  rather  firmly,  but  not  too  tightly,  to  the  thread 
which  projects  from  the  saphenous  opening;  this  fixes  the  sac  in  its  place, 
and  fixes  Poupart's  ligament  to  the  pectineus  muscle,  so  obliterating  the 
crural  canal.  If  necessary,  a  second  suture  may  be  put  in  for  this  pur- 
pose, but  nearer  the  pubic  spine.  A  suture  is  put  in  to  close  the  hole 
above  Poupart's  ligament  and  the  skin  incision  is  closed.  Thus  there  are 
three  distinct  checks  against  the  recurrence  of  the  hernia:  (i)  The  sac 
is  ligatured  higher  up  than  is  possible  by  the  ordinary  method  and  leaves 
no  peritoneal  pouch;  (2),  the  sac  is  used  as  a  buffer  or  roof  above  the 
crural  canal;  and,  (3),  Poupart's  ligament  is  approximated  to  the  pectineus 
muscle  and  obliterates  the  crural  canal.  It  may  be  urged  that  the  sac  will 
slough  and  cause  trouble.  This  does  not  take  place.  It  no  doubt  becomes 
vascularized,  converted  into  granulation  tissue,  and  ultimately  into  fibrous 
tissue. 

In  strangulated  hernia,  when  it  has  seemed  safe  to  leave  the  sac,  and 
when  time  was  precious,  the  author  has  modified  the  operation  by  pushing 
the  sac  up  through  the  canal,  after  having  made  a  little  space  for  it  as  be- 
fore, and  then  sutured  Poupart's  ligament  to  the  pectineus  muscle. 

POLYA'S  OPERATION. 

The  feature  of  Polya's  operation  is  the  obliteration  of  the  femoral 
canal  by  plugging  it  with  the  entire  thickness  of  the  sartorius  muscle 
(Ceutralbl.  f.  Chirurgie.  Vol.  XXXII,  Xo.   18). 


294  RADICAL     CURE     OF     FEMORAL      HERNIA' 

The  incision  is  in  the  shape  of  a  T  or  inverted  L.  The  saphena  is 
hg-ated  and  severed,  and  the  hernial  sac  tied  and  buried  if  possible.  The 
sheath  of  the  sartorius  is  slit  across  below  the  level  of  the  canal,  and  the 
sartorius  muscle  is  cut  a  trifle  above  this  slit.  The  proximal  stump  of  the 
muscle  is  then  worked  through  the  saphenous  opening  above  the  large 
vessels  and  sutured,  after  being  pushed  as  far  into  the  canal  as  it  can  be 
made  to  go.  Two  or  three  stout  catgut  threads  are  passed  through  Pou- 
part's  ligament,  the  implanted  sartorius  and  the  sheath  of  the  pectineus, 
and  the  muscle  is  pulled  deep  into  the  femoral  canal  as  the  threads  are 
tied.  A  flap  is  made  by  cutting  the  fascia  lata,  and  it  is  turned  back  and 
sutured  to  Poupart's  ligament,  to  the  sheath  of  the  pectineus  and  to  the 
sartorius  below. 

The  operation  has  been  performed  a  number  of  times  with  very  satis- 
factory results.  One  of  the  patients  operated  on  succumbed  not  long  after 
to  an  intercurrent  infectious  disease,  and  the  autopsy  demonstrated  the  per- 
fect anatomic  results  obtained  by  this  technic. 

MIKULICZ'S  OPERATION. 

C.  Goebel  (Bcitrlige  s.  Klin.  Chir..  1904)  described  a  procedure  em- 
ployed by  von  Mikulicz,  the  principal  feature  of  which  is  the  utilization 
of  the  periosteum  of  the  os  pubis  for  the  formation  of  a  double  flap.  The 
technic  consists,  briefly,  of  the  isolation,  ligation,  and  submersion  of  the 
hernial  sac.  An  incision  is  made  extending  down  to  the  bone,  from  the 
tuberosity  of  the  pubis  to  the  vessels,  in  a  frontal  direction  and  slightly 
anterior  to  the  crest  of  the  pubis.  An  upper  and  lower  periosteal  (perios- 
teal-muscle-fascia)  flap  is  then  formed  out  of  the  os  pubis,  if  necessary 
with  sagittal  section  across  the  bone  at  the  outer  and  inner  end  of  the 
frontal  incision.  Suture  of  the  upper  (inner)  periosteal  flap  to  the  outer 
border  of  the  ligament  is  the  next  step  in  the  operation,  and  this  is  followed 
by  a  subcutaneous  suture  of  the  rem.aining  fascia,  and  suture  of  the  skin. 

The  advantage  of  this  method  is  said  to  be  that  the  turned-up  perios- 
teum joined  to  Poupart's  ligament  causes  an  ideal  closure  of  the  crural 
canal  at  its  entrance  at  the  very  beginning  of  the  femoral  infundibulum. 
In  May,  1895  (Annals  of  Surgery)  I  published  a  method  of  raising  the 
periosteal  flap. 

KAMMEREE'S  OPERATION. 

F.  Kammerer  (AjuuiIs  of  Surgery.  June,  1904)  discusses  the  various 
operations  that  have  been  devised  for  the  cure  of  femoral  hernia.  He 
employed  Lotheisen"s  method  for  a  time  and  then  abandoned  it  in  favor 
of  Salzer's  method,  but  Kammerer  includes  in  the  flap  a  laver  of  muscular 
tissue  taken  from  the  pectineus  muscle,  which,  in  persons  who  have  worn 
a  truss,  is  quite  firm.  Up  to  the  time  of  writing  he  had  performed  this 
operation  ten  times.  In  the  only  two  cases  that  could  be  traced  after  the 
operation,  one,  a  woman,  aged  34,  operated  on  in  1902,  for  a  right  reducible 
femoral  hernia,  and  the  other,  a  woman,  aged  50,  operated  on  also  in  1902, 


I 


PLATE  LIL 
Fabricius'  Operation  for  Femoral  Hernia  (Fowler). 


RADICAL     CCRE     OF     FEMORAL     HER^'IA  297 

for  a  double   femoral  hernia,  neither  patient  has   since  worn  a  truss  nor 
has  there  been  a  recurrence  of  the  hernia. 

In  1903  he  employed  Lotheisen's  method  in  a  case  of  incarcerated 
femoral  hernia  of  very  large  size  containing-  adherent  omentum  and  a 
large  knuckle  of  small  intestine  very  much  discolored.  He  divided  Poupart's 
ligament  immediately  over  the  neck  of  the  sac,  cutting  from  within  out- 
ward, as  advised  by  Lotheisen.  In  five  other  cases  of  femoral  hernia  oper- 
ated on  the  ligament  was  not  divided.  The  result  in  all  of  these  cases  was 
good.  Kammerer  says  that  dividing  the  constriction  from  within  in  an 
outward  direction  is  a  procedure  that  should  be  relegated  to  the  past.  A 
cross  section  of  Poupart's  ligament  from  without,  cutting  down  on  the 
neck  of  the  sac,  is  much  more  satisfactory  when  it  starts  from  a  previous 
incision  into  the  aponeurosis  of  the  external  oblique.  In  the  case  men- 
tioned above,  he  fastened  the  cut  ligament  to  the  internal  oblique  muscle 
after  the  latter  had  been  sutured  to  Poupart's  ligament. 

NICOLL'S  OPERATION. 

The  main  feature  of  XicoU's  operation  {Annals  of  Surgery,  January, 
1906)  are  (a)  the  employment  of  the  sac  to  form  an  intra-abdominal  but- 
tress over  the  internal  aspect  of  the  hernial  opening  or  ring;  (b)  the  use 
of  the  pubic  ramus  as  a  point  d'appui  in  the  process  of  closure  of  the 
hernial  canal,  and  (c)  the  additional  security  of  closure  obtained  by  the 
supraposition  on  the  bone  sutures  of  a  plane  of  fascial  sutures.  A  vertical 
or  transverse  incision  exposes  the  sac,  which  is  opened  longitudinally  in 
its  middle  line  and  emptied.  The  sac  is  separated  from  parts  surrounding 
its  neck  for  one  inch  around  the  abdominal  aspect  of  the  ring,  and  bisected 
longitudinally  from  fundus  to  neck.  Make  an  aperture  in  one-half  near 
the  neck  and  interlock  the  halves  by  putting  one  through  this  aper- 
ture. Reduce  the  whole  sac  through  the  femoral  ring  into  the  extra- 
perintoneal  space  previously  cleared  by  detaching  its  neck  from  the  ab- 
dominal aspect  of  the  ring.  The  sac  thus  lies  bunched  up  within  the  ab- 
domen betw^een  the  peritoneum  and  the  transversalis  and  iliac  fascia  over 
the  hernial  aperture  of  the  femoral  canal. 

The  femoral  ring  is  closed  as  follows :  Carry  a  bone-deep  incision 
from  the  femoral  ring  along  the  pubic  ramus  to  the  region  of  the  pubic 
spine,  dividing  the  pubic  portion  of  the  fascia  lata,  the  origin  of  the  pec- 
tineus  and  the  periosteum.  Detach  the  latter  to  a  limited  extent  and  re- 
tract it.  Drill  the  bone  near  its  upper  edge  in  two  places,  one-half  to  one 
inch  apart.  Pass  through  one  of  the  apertures  a  loop  or  stout  catgut  or 
other  absorbable  ligature,  and  divide  the  loop  of  the  ligature.  Thread 
one  end  in  a  large  curved  surgical  needle  and  pass  it  as  a  mattress  suture 
through.  Poupart's  ligament.  Repeat  this  procedure  with  the  second  end 
of  the  ligature  at  a  higher  level,  avoiding  the  deep  epigastric  artery  to  the 
outer  side,  and,  in  male  patients,  the  spermatic  cord  above.  Withdraw 
both  ligatures  through  the  second  drill-hole  in  the  bone  ;  tie  the  ends  of 
each  loop  separately  over  the  front  of  the  bone,  thus  bringing  Poupart's 
ligament   down  to  the   postero-superior   surface   of  the   bone,   fastening   it 


298  RADICAL     CURE     OF     FEMORAL     HERNIA 

firmly  in  contact  with  that  surface,  constituting  what  is  in  fact  an  ex- 
tension outward  of  Gimbernat's  ligament  and  absolutely  closing  the 
femoral  ring  to  whatever  extent  may  be  desired.  To  make  the  closure 
doubly  secure  the  operation  is  completed  by  uniting  by  interrupted  catgut 
sutures  the  attached  margin  of  the  pectineal  origin  and  the  pubic  portion 
of  the  fascia  lata  to  the  anchored  Poupart's  ligament. 

DE  GARMO'S  OPERATION. 

The  technic  of  the  operation  employed  by  W.  B.  De  Garmo  (Annals 
of  Surgery,  August,  1905)   is  as  follows: 

The  incision  should  be  between  two  and  three  inches  long,  parallel 
with  and  to  the  inner  side  of  the  femoral  vessels.  The  upper  angle  of  the 
wound  should  be  well  up  over  Poupart's  ligament  and  extend  down  over 
the  saphenous  opening.  When  the  skin  and  the  superficial  fascia  are  in- 
cised, usually  the  sac  and  its  subperitoneal  fat  will  come  into  the  wound 
with  the  appearance  of  an  encysted  lipoma  and,  before  separating  the  sac, 
it  is  best  that  this  entire  mass  should  be  lifted  out  of  its  bed  by  thumb  for- 
ceps and  blunt  dissection,  so  that  its  neck  where  it  passes  under  Poupart's 
ligament  shall  be  entirely  free  from  its  surrounding.  By  traction  on  the 
sac  and  its  superimposed  fat  this  neck  may  not  only  be  freed,  but  it  will 
be  materially  lengthened,  so  that  when  it  is  finally  ligated  and  cut  off  it 
will  retract  within  the  abdominal  cavity,  leaving  the  femoral  canal  free  of 
foreign  tissue.  This  is  absolutely  essential  to  a  subsequent  permanent 
cure.  The  sac  should  be  opened,  and  where  the  omentum  is  found  adher- 
ent it  should  be  carefully  ligated.  cut  away,  and  its  stump  reduced  to  the 
abdominal  cavity.  Adherent  intestine  will  rarely  be  found,  but  when  it  is 
the  adhesions  must  either  be  broken  up  or,  if  too  firm,  the  adherent  part 
may  be  cut  out  of  the  sac  and  left  attached  to  the  bowel.  When  in  doubt 
the  latter  method  is  b}^  far  the  safer.  Adherent  omentum  is  frequently 
found  and  should  be  cut  away  after  careful  ligation.  The  sac  having 
been  entirely  freed  of  its  contents,  is  tied  off  as  high  as  possible,  while  it 
is  being  forcibly  drawn  down  by  an  assistant.  Great  care  must  be  used 
to  insure  the  perfect  freedom  of  the  neck  of  the  sac  from  protruding 
bowel  or  omentum  while  the  ligature  is  being  placed.  After  tying  with 
strong  catgut  (a  double  strand  of  No.  2  plain  is  preferred),  pass  the 
needle,  which  has  been  previously  threaded  v/ith  it,  through  the  neck  of 
the  sac  and  tie  again.  This  gives  a  double  hgature  anchored  by  perfora- 
tion between  the  two,  and  prevents  slipping  off.  When  the  sac  is  cut  away 
the  stump  .should  be  examined  to  be  sure  that  no  bleeding  vessels  remain, 
and  not  until  then  should  the  ends  of  the  ligature  be  cut.  When  the  liga- 
ture is  cut  the  stump  usually  retracts  within  the  abdomen.  If  this  is  pre- 
vented by  connective  tissue  which  has  not  been  broken  it  should  be  care- 
fully pushed  back,  leaving  the  femoral  opening  absolutely  free.  This  open- 
ing is  closed  by  good-sized  kangaroo  tendon  threaded  in  a  strong,  blunt 
needle  by  pressing  the  end  of  the  finger  firmly  into  the  femoral  opening 
under  Poupart's  ligament,  and  passing  the  needle  throug"h  the  ligament 
on   the   finger-point.     This   perforation   should   be   well   toward   the   outer 


RADICAL     CURE     OF     FEMORAL     HERXIA  299 

side  of  the  canal  and  close  to  the  femoral  vein.  The  operator  should 
assure  himself,  by  pressure  of  the  finger  against  the  ramus  of  the  pubes, 
that  the  vessels  are  out  of  the  way,  and  pass  the  point  of  the  needle  fully 
down  to  the  periosteum  of  the  pubic  bone,  raking  up  all  tissues  over  it. 
This  constitutes  the  first  stitch,  but  should  not  be  tied  until  the  others  are 
in  place.  Others  should  then  be  placed  in  the  same  manner,  every  quar- 
ter of  an  inch  apart,  until  near  the  spine  of  the  pubes.  Usually  three  or 
four  will  completely  close  the  femoral  opening.  When  tied  down  and 
the  ends  cut  moderately  close,  the  fascia  should  be  closed  in  by  plain  cat- 
gut, to  avoid  a  pocket  in  the  tissues  that  otherwise  may  result,  and  the 
skin  may  then  be  closed  by  buried  sutures  of  plain  catgut.  The  wound  is 
covered  by  collodion  and  a  compress  of  sterilized  gauze,  held  in  place  by 
a  figure-of-eight  bandage.  In  ten  days  the  dressings  are  changed  and  a 
bandage  for  temporary  support  is  applied.  If  healing  has  been  complete, 
the  patient  is  allowed  to  sit  up  on  the  tenth  day  and  to  leave  the  house 
on  the  fourteenth  day  after  the  operation.  The  bandage  used  after  the 
first  dressing  consists  of  a  pelvic  belt,  of  three  thicknesses  of  canton  flan- 
nel, with  a  compress  of  gauze  over  the  former  site  of  the  hernia,  and  a 
perineal  strap  to  prevent  its  slipping  up.  This  is  to  be  worn  for  four 
weeks.     No  truss  or  other  permanent  support  should  be  worn. 

HEEZEIT'S  OPERATION. 

P.  Herzen,  after  tying  and  removing  the  hernial  sac,  and  reducing 
the  stump,  detaches  the  femoral  vein,  draws  it  to  one  side,  and  Poupart's 
ligament  upward.  He  then  dissects  a  flap  of  periosteum  from  the  upper 
aspect  of  the  pubis  about  the  width  of  the  femoral  canal,  and  about  one 
to  1.5  centimeters  long,  the  base  of  the  flap  resting  on  the  pectineus  mus- 
cle. This  flap  is  then  detached  from  the  bone  and  turned  back  down- 
ward. Two  to  four  small  holes  are  then  drilled  through  the  pubis  in 
such  a  way  that  the  drill  emerges  always  in  the  part  exposed  by  the  rais- 
ing of  the  flap.  The  two  ends  of  a  bronze  aluminum  wire  are  then  passed 
from  behind  forward  through  Poupart's  ligament  and  through  two  of 
these  holes.  By  pulling  on  the  wire  the  ligament  is  brought  into  intimate 
contact  with  the  exposed  part  of  the  pubis.  The  flap  of  periosteum  is 
then  replaced  and  fastened  with  a  couple  of  stitches.  By  this  means  the 
femoral  ring  is  entirely  closed,  the  ligament  having  taken  its  place  and 
being  re-enforced  by  the  periosteal  flap. 

OCHSNEE'S  OPERATION. 

For  the  past  fourteen  years  A.  J.  Ochsner  has  used  a  method  which 
has  not  been  followed  by  recurrence  in  any  one  of  the  thirty  patients 
that  can  be  traced.  The  principle  underlying  the  method  is  to  change 
the  femoral  canal  into  an  unlined  circular  opening,  which  will  close  spon- 
taneously. In  order  to  effect  this  Ochsner  dissects  out  the  hernial  sac 
quite  up  into  the  peritoneal  cavity  beyond  the  inner  surface  of  the  femoral 
ring,  ligates  it  high  up  (Fig.  53),  cuts  it  off,  and  permits  the  stump  to 
withdraw   wdthin   the   peritoneal   cavity.      Removing   all   the    fat   contained 


300  RADICAL     CURE     OF     FEMORAL     HERNIA 

in  the  femoral  canal  and  simply  closing  the  skin  wound  completes  the 
operation.  Ochsner  claims  that  this  method  is  applicable  to  all  simple 
femoral  hernias  in  which  an  actual  femoral  ring  exists.  The  method  is 
not  appHcable  to  cases  of  strangulated  hernia  in  which  the  femoral  ring 
has  to  be  cut  to  permit  of  reduction  of  the  hernia. 

SOCIN'S  OPERATION. 

In  Socin's  operation  the  skin  incision  is  made  a  little  below  and 
parallel  with  Poupart's  ligament.  The  sac  is  then  freed  high  up  into  the 
abdominal  cavity  and  all  the  fat  and  loose  tissue  removed.  The  sac. 
after  being  pulled  down  by  an  assistant,  is  ligated  and  cut  off  high  up,  the 
stump  being  allowed  to  slip  back  easily  into  the  peritoneal  cavity.  The 
skin  incision  is  sutured  according  to  the  preference  of  the  individual  oper- 
ator. 

COLEY'S  OPERATION. 

W.  B.  Colev  frees  the  sac  well  beyond  its  neck  and  then  ligates  ii 
high  up.  A  suture  is  then  introduced  through  Poupart's  ligament  or  the 
inner  portion  of  the  canal  or  crural  arch,  thence  passed  downward  into 
the  pectineus  muscle  or  lioor  of  the  canal,  outward  through  the  fascia 
lata  overlying  the  femoral  vein,  and  upvv-ard  through  Poupart's  ligament 
or  the  roof  of  the  canal,  emerging  about  three-fourths  of  an  inch  from 
the  point  of  its  introduction.  On  tying  the  suture  the  iioor  of  the  canal 
is  brought  in  apposition  with  the  roof  of  the  canal  and  the  femoral 
opening  is  obliterated.  The  superficial  fascia  is  brought  together  with 
catgut  or  fine  tendon,  and  the  skin  sutured  with  horsehair. 

CURTIS'  OPERATION. 

Curtis  closes  the  canal  after  the  sac  has  been  removed  by  introducing 
three  superimposed  circular  purse-string  sutures  of  catgut,  the  first  at  the 
internal  femoral  opening,  the  second  One-third  of  an  mch  outside  of  this, 
and  the  third  at  the  external  surface  of  the  canal.  The  method  is  said  not 
to  be  suitable  for  large  hernias. 

LOTHEISSEN'S  OPERATION. 

In  this  method  the  external  incision  is  made  parallel  to  and  a  little 
above  Poupart's  ligament  so  as  to  divide  the  fibers  of  the  external  oblique 
and  extend  into  the  external  inguinal  ring.  The  neck  of  the  sac  is  ex- 
posed by  entering  between  Poupart's  ligament  and  the  internal  oblique 
muscle.  The  sac  is  dislocated,  if  small,  by  pulling  it  into  the  opening 
above  Poupart's  ligament.  In  large  hernias  the  skin  is  dislocated  at  the 
lower  edge  of  the  original  incision  so  as  to  expose  the  external  surface  of 
the  sac.  The  sac  is  then  incised  and  the  stump  dislocated  in  the  same  man- 
ner as  for  small  hernias.  The  edges  of  the  transversalis  and  internal 
oblique  muscles  are  sutured  to  Cooper's  ligament.  The  incisions  in  the 
aponeurosis  and  the  skin  are  sutured  separately. 


PLATE  LIII. 
Ochsner's   Operation   for  Femoral  Hernia. 


RADICAL     CURE     OF     FEMORAL     HERNLV  3O3 

HAMMESFAHR'S  OPERATION. 

After  the  femoral  sac  is  resected  and  the  stump  reduced,  three  holes 
are  drilled  in  the  upper  margin  of  the  pubic  ramus  from  the  slant  upward 
so  that  the  inner  opening  is  close  beneath  the  edge  of  the  crest.  Strong 
silk  is  then  passed  around  Poupart's  ligament  and  then  through  the  holes, 
and  is  tied  firmly. 

Salzer  devised  a  method  of  closing  the  femoral  canal  which  met  with 
considerable  favor  because  of  the  permanency  of  the  result  obtained.  He 
employed  a  flap  made  from  the  fascia  of  the  pectineus  muscle.  The  flap 
was  formed  by  making  a  curved  incision,  with  the  convexity  directed 
downward,  from  the  crista  pectinea  to  Gimbernat's  ligament.  It  was  then 
turned  upward  and  sutured  with  strong  catgut  to  the  lower  margin  of  the 
inner  third  of  Poupart's  ligament.  The  sheath  of  the  pectineus  muscle 
was  restored  by  a  few  buried,  absorbable  sutures. 

SPRENGEL'S  METHOD. 

At  the  last  meeting  of  the  German  Congress  of  Surgery,  Sprengel 
proposed  a  new  procedure  for  the  treatment  of  certain  femoral  hernias 
in  women,  consisting  of  the  closure  of  the  internal  ring  of  the  femoral 
canal  through  the  abdominal  cavity.  The  operation  consists  of  the  fol- 
lowing steps:  I.  Free  exposure  of  the  sac  by  linear  incision,  opening 
and  examination  of  the  same,  and  clearing  of  the  impacted  contents.  2. 
Transrectus  laparotomy  on  the  side  of  the  hernia,  damming  back  of  the 
intestines  and  the  organs  of  the  lesser  pelvis.  3.  Introduction  of  a  Mik- 
ulicz forceps  through  the  fem^oral  canal  into  the  sac,  and  invagination  of 
the  same  into  the  abdominal  cavity.  4.  Firm  rolling  together  of  the  sac 
and  suturing  of  it  over  to  the  internal  ring,  together  with  pulling  forward 
and  suturing  of  the  round  ligament  of  the  uterus  lying  in  the  immediate 
neighborhood  of  the  inguinal  canal.  5.  Closure  of  the  abdominal  incision 
and  the  linear  one  over  the  femoral  canal. 

The  method  was  tried  in  five  cases,  one  being  of  ten  months'  duration, 
and  gave  a  perfectly  satisfactory  result.  According  to  Sprengel,  the 
method  is  adapted  particularly  to  old  hernias  of  a  large  size  and  to  re- 
current cases.  The  method  appears  to  he  a  very  simple  one,  but  it  is  im- 
possible to  judge  of  its  value  until  a  larger  number  of  patients  has  been 
operated  and  more  time  has   elapsed  after  the  operation. 

SCHWARTZ'S  OPERATION. 

For  the  cure  of  a  femoral  hernia,  Schwartz  takes  a  flap  from  the 
second  or  median  adductor.  It  is  raised,  forced  into  the  crural  canal, 
and  fixed  by  sutures  to  the  surrounding  cellular  tissue  and  to  the  lower 
border  of  Poupart's  ligament.  This  forms  a  true  flap  of  muscle  which 
fills  the  crural  infundibulum  and  reaches  to  the  ring-  itself. 


CHAPTER  VI. 

RADICAL  CURE  OF  UMBILICAL  HERNIA. 

Women  are  usually  the  ones  who  suffer  from  this  form  of  hernia 
and  as  a  rule  they  are  obese,  multiparas  with  very  large  hernial  openings, 
the  recti  muscles  are  widely  separated,  and  from  long-continued  pressure 
they  become  considerably  atrophied.  If  an  ordinary  abdominal  section  is 
done  in  these  cases,  difficulty  will  be  encountered  in  attempting  to  close 
the  opening  by  bringing  like  structures  in  apposition,  as  is  usually  done, 
unless  transplantation  of  the  recti  muscles  is  resorted  to.  However,  this 
is  neither  necessary  nor  is  it  successful,  except  in  the  case  of  a  small 
hernia,  and  then  it  is  the  operation  of  choice. 

W.  J.  MAYO'S  OPEEATION. 

In  1898  W.  J.  Mayo,  of  Rochester,  Minnesota,  called  attention  to  the 
impracticability  of  covering  in  the  defect  left  by  the  excision  of  a  large 
umbilical  hernia  with  muscle,  and  advocated  the  overlapping  of  the 
aponeurotic  structures  which  are  already  at  hand,  thus  securing  a  wide 
area  of  adhesions.     Mayo  described  his  operation   (Fig.  54)   as  follows: 

Transverse  elliptical  incisions  are  made  including  the  umbilicus  and 
the  hernia.  The  surfaces  of  the  aponeurotic  structures  are  cleared  two 
and  a  half  to  three  inches  in  all  directions  from  the  neck  of  the  sac.  'The 
fibrous  and  peritoneal  coverings  of  the  hernia  are  divided  in  a  circular  man- 
ner at  the  neck  of  the  sac,  thus  exposing  its  contents.  If  intestinal  viscera 
are  present,  the  adhesions  are  separated  and  restitution  is  made.  The 
omentum  is  ligated  and  removed  with  the  sac  of  the  hernia,  without  dis- 
section of  the  adherent  portion  of  the  omentum. 

An  incision  is  made  through  the  aponeurotic  and  peritoneal  structures 
of  the  ring  extending  one  inch  or  less  transversely  to  each  side,  and  the 
peritoneum  is  separated  from  the  under  surface  of  the  upper  of  the  two 
flaps  thus  formed. 

Beginning  from  two  to  two  and  one-half  inches  above  the  margin 
of  the  upper  flap,  three  to  four  mattress  sutures  of  silk  or  other  perma- 
nent material  are  introduced,  the  loop  firmly  grasping  the  upper  margin 
of  the  lower  flap;  sufficient  traction  is  made  on  these  sutures  to  enable 
peritoneal  approximation  with  running  or  interrupted  suture  of  catgut. 
The  mattress  sutures  are  then  drawn  into  position,  sliding  the  entire  lower 
flap  into  the  pocket  previously  formed  between  the  aponeurosis  and  the 
peritoneum  above. 

The  free  margin  of  the  upper  flap  is  fixed  by  catgut  sutures  to  the 
surface  of  the  aponeurosis  below,  and  the  superficial  incision  closed  in  the 
usual    manner.      In   the    larger   hernias    the    incision    throusrh    the    fibrous 


PLATE  LIV. 
Mayo's  Operation  for  Umbilical  Hernia, 


I 


RADICAL     CURE    OF     UMBILICAL     HLRNIA  307 

coverings  of  the  sac  may  be  made  somewhat  above  the  base,  thereby  in- 
creasing the  amount  of  tissue  to  be.  used  in  the  overlapping  process   ( Fig. 

55)- 

In  the  very  large  protrusions   in  which  part  of   the  hernial   contents 

is  irreducible  the  patient  should  be  kept  in  bed  on  a  reduced  diet  and 
directed  to  manipulate  the  hernia,  with  the  intention  of  replacing  as  much 
as  possible.  The  irreducible  portion  must  not  be  forced  into  the  abdom- 
inal cavity  after  losing  the  "right  of  habitation."  If  this  consists  of  omentum 
only,  it  is  readily  disposed  of  by  excision ;  if  intestine,  enough  omentum 
previously  contained  in  the  peritoneal  cavity  should  be  removed  to  allow  of 
reduction  of  the  bowel  without  pressure. 

The  patients  should  be  kept  in  bed  three  or  four  weeks  after  opera- 
tion and  after  getting  about  should  not  apply  a  truss,  although  most  of 
them  prefer  to  wear  an  abdominal  supporter  for  a  year. 

Piccoli  (Ccntralblatt  filr  klinische  Chiriirgie,  Jan.  13,  1900)  reports 
a  case  successfully  operated  on  in  August,  1899,  after  the  lateral  plan,  and 
refers  to  a  case  reported  by  Bonomo,  operated  on  Dec.  9,  1899,  with  a 
favorable  result. 

J.  A.  Blake  (Medical  Ass'n  of  Greater  New  York,  J^n.  14,  1901) 
reports  several  cases  operated  on  by  the  lateral  method  during  the  year 
1900,  and  refers  to  an  article  by  Sapiejko  (Rev.  de  Chir.,  1900,  No.  2,  p. 
240)   in  which  a  lateral  operation  is  described. 

The  writer  (Mayo)  had  described  and  operated  by  the  lateral  over- 
lapping plan  several  years  before  the  cases  reported  by  these  authors 
and  found  the  lateral  a  good  operation,  but  it  is  not  as  good  as  the  ver- 
tical method,  in  which  the  retaining  structures  are  given  a  bearing  point 
above  the  site  of  the  umbilicus  and  intra-abdominal  pressure  thus  acts 
to  prevent  separation  instead  of  aiding  it. 

BLAKE'S  OPERATION. 

J.  H.  Blake  claims  that  the  method  which  is  particularly  applicable 
to  the  cases  in  which  there  is  stretching  of  the  linea  alba  with  separa- 
tion of  the  recti  muscles  is  that  of  lapping  the  abdominal  walls.  This 
method  consists  of  the  division  of  the  linea  alba  above  and  below  the  sac 
in  the  median  line  for  the  necessary  distance,  with  or  without  excision 
of  the  ring  and  a  portion  of  the  linea  alba.  The  entire  wall  on  one  side 
is  then  lapped  in  front  of  the  other  and  there  sutured,  so  that  the  ventral 
surface  of  the  one  side  is  in  contact  with  the  dorsal  surface  of  the  other 
(Fig.  56).  Three  patients  were  operated  on  after  this  method,  with  good 
immediate  results.  The  suture  miaterial  used  was  plain  catgut  for  the 
peritoneum.  No.  2  chromicized  catgut  for  the  aponeurosis  and  muscles, 
and  silkworm  gut  and  silk  for  the  skin.  Two  points  in  the  technic  are 
emphasized,  the  absolute  cleansing  of  fat  from  the  rectus  sheath, 
which  is  to  be  applied  to  the  back  of  the  opposite  rectus,  and  the  inser- 
tion of  the  mattress  sutures,  so  that  they  wall  be  in  the  course  of  the 
muscle  fibers,  and  not  strangulate  them.  It  has  been  found  more  conve- 
nient to  have  the  mattress  sutures  threaded  on  two  needles.     The  sutures 


308  RADICAL     CURE    OF     UMBILICAL     IlERNIA 

include  about  one-third  of  an  inch  of  tissue,  and  are  placed  about  five- 
eighths  of  an  inch  apart.  Some  of  the  more  apparent  advantages  of 
the  method  are  the  doubling  of  the  abdominal  wall  at  the  hernial  site ;  the 
breaking  of  the  lines  of  suture;  a  broad  surface  for  union;  the  oblitera- 
tion of  the  separation  of  the  recti,  and  the  reduction  in  the  size  of  the 
abdomen. 

In  applying  the  mattress  sutures  along  the  edge  of  the  inner  flap, 
and  to  the  peritoneum,  care  must  be  taken  not  to  leave  a  raw  edge  on 
the  peritoneal  aspect  in  order  to  prevent  adhesions.  If  a  little  care  is  taken 
to  fit  the  flaps  properly  at  the  upper  and  lower  corners,  a  uniform  pres- 
sure on  the  abdominal  organs  is  obtained.  In  several  cases  I  have  liberated 
the  recti  muscles  ver}^  freely  after  sev/ing  the  peritoneum  and  the  aponeu- 
rotic structures,  bringing  the  tv\^o  recti  muscles  together  in  the  mid-line 
(Figs.  57,  58,  59,  60). 

BOECKEL'S  OPERATION. 

Boeckel  makes  an  elliptical  incision,  removing  the  umbilicus  with 
the  sac.  Chain  sutures  are  inserted  to  close  the  peritoneum.  The  fibrous 
edges  are  freshened  even  to  the  muscular  structures  of  the  recti,  if  nec- 
essary. Kangaroo  tendon  or  chromic  catgut  is  employed  to  coapt  the 
fibro-muscular  structures. 

DATJRIAC'S  OPERATION. 

In  this  method  both  recti  muscles  are  exposed  through  a  median 
incision,  or  the  incision  may  be  made  elliptical.  The  sac  is  ablated  and 
then  the  peritoneum  is  closed.  The  next  step  in  the  operation  is  to  cross 
a  portion  of  the  right  rectus  muscle  over  to  the  left  side,  and  a  portion 
of  the  left  rectus  muscle  over  to  the  right  side,  thus  forming  an  X  of 
muscular  tissue,  the  center  of  the  X  being  placed  over  the  center  of  the 
spot  occupied  by  the  hernia. 

This  is  done  by  dividing  each  muscle  into  two  portions  by  two  in- 
cisions, a  longitudinal  incision  and  a  transverse  incision,  the  former  be- 
ing placed  nearer  to  the  inner  than  to  the  outer  border  of  the  muscle. 
The  transverse  incision  passes  through  the  inner  portions  of  the  muscles 
transversely  at  their  upper  ends,  including  the  corresponding  part  of  the 
muscle  sheath.  In  Greig  Smith's  operation  the  inner  borders  of  the  recti 
muscles  are  liberated  by  a  free  separation  of  the  margins  of  the  ring  and 
they  are  sutured  together  with  buried  sutures. 

Quenu  recommends  six  layers  of  sutures  coapting  like  structures,  as 
follows:  (i)  Peritoneum;  (2)  fascia;  (3)  posterior  border  of  the  rec- 
tus muscle;  (4)  rectus  muscle;  (5)  anterior  border  of  the  rectus  muscle; 
(6)   subcutaneous  soft  structures;   (7)   skin. 

DEAVER'S  OPERATION. 

Deaver's  operation  difTers  slightly  from  the  usual  omphalectomy.  The 
sac  is  disposed  of  in  the  customary  manner.  The  recti  muscles  are  ex- 
posed by  incising  the  anterior  walls  of  their  sheaths  near  the  linea  alba  on 
each  side  of  the  wound,  and  thev  are  then  brought  together  bv  sutures 


RADICAL     CURE    OF     UMBILICAL     HERNIA  3O9 

which  are  passed  through  them  and  the  anterior  walls   of  their   sheaths, 
from  within  outward. 

Barker,  Bennett,  Keetlev,  Ball,  Macewen,  and  AIcGill  laid  great  stress 
on  the  importance  of  retaining  the  sac,  twisting  the  stump  and  sewing 
the  other  structures  in  front  of  it. 

OMPHALECTOMY. 

This  is  the  ideal  operation  for  the  cure  of  an  umbilical  hernia  of 
moderate  size,  and  in  women  with  lax  abdominal  walls  who  have  borne 
children,  hernias  of  considerable  size  can  be  dealt  with  successfully  by 
doing  an  omphalectomy,  as  was  pointed  out  by  Joseph  Ransohoff,  of  Cin- 
cinnati, who  in  1897,  reported  three  cases  of  this  kind  in  which  the  opera- 
tion was  entirely  successful. 

In  the  para-umbilical,  sub-umbilical  and  supra-umbilical  varieties,  the 
conditions  present  must  determine  whether  or  not  the  umbilicus  is  to  be 
removed.  If  the  hernia  is  a  very  small  one,  the  umbilicus  need  not  be  re- 
moved, but  the  rule  is  to  ablate  it. 

WARREN'S  OPERATION. 

J.  Collins  Warren,  of  Boston,  believes  that  in  view  of  the  fact  that 
the  vertical  diameter  of  the  opening  in  these  cases  is  always  .shorter  than 
the  transverse,  better  results  will  be  obtained  by  bringing  the  lower  and 
upper  margins  of  the  ring  together,  rather  than  the  lateral  edges.  He 
uses  silk  for  his  buried  sutures.  In  one  case,  the  patient  being  46  years 
old,  a  case  of  recurrent  hernia,  the  result  was  excellent  ten  years  after 
the  operation.  The  patient  had  worn  a  belt  since  the  operation.  Of 
eleven  cases  operated  by  this  method,  in  only  one  was  a  recurrence  reported 
during  periods  of  from  one  to  thirteen  years,  about  9  per  cent. 

WINSLOW'S  OPERATION. 

K.  Winslow  (Annals  of  Surgery,  Feb.,  1904)  states  that  the  aponeu- 
rotic coverings  are  the  chief  supporting  structures  of  the  abdominal  walls 
and  that  their  approximation  by  overlapping  in  doubling  the  strength  of 
the  aponeurotic  layers  doubles  the  strength  of  the  abdominal  incision.  His 
technic  for  the  prevention  of  abdominal  hernia  by  overlapping  the  aponeu- 
rosis is  described  as  follows : 

The  integument  and  subcutaneous  tissue  are  incised  down  to  the 
aponeurosis.  This  is  bared  by  reflecting  back  the  skin  and  fat  for  the  space 
of  an  inch  and  a  half  on  the  side  of  the  incision.  The  aponeurosis  is 
then  incised  in  the  same  line  and  directly  beneath  the  skin  incision,  and 
the  two  flaps,  one  on  each  side  of  the  incision,  are  raised  from  the  under- 
lying muscle  by  blunt  dissection.  One  flap  of  aponeurosis  is  freed  for 
an  inch  or  so  from  its  cut  margin  and  the  other  for  about  half  that  dis- 
tance. The  incision  through  the  rest  of  the  abdominal  wall  is  completed 
as  usual.  In  closing  the  peritoneum  is  approximated  by  continuous  suture. 
In  weak,  fatty  walls  it  is  wise  to  introduce  two  or  three  retention  sutures 
placed  well  back  from  the  margins  of  the  wound  and  penetrating  the  layers 


3IO  RADICAL     CURE    OF     UMBILICAL     HERNIA 

above  the  peritoneum.  The  muscle,  if  well  developed,  is  coaptated  by 
interrupted  sutures,  then  the  cut  edge  of  the  aponeurotic  flap  which  was 
but  slightly  freed  is  stitched  to  the  base  of  the  opposing  flap  by  interrupted 
or  mattress  sutures.  The  free  margni  of  the  opposing  flap  is  lapped  over 
the  other  one  and  stitched  down  to  the  surface  of  the  aponeurosis  by  in- 
terrupted or  continuous  suture.  A  drain  of  gauze  wrapped  about  with 
rubber  tissue,  or  a  roll  of  rubber  tissue  alone,  emerging  from  the  lower 
angle  of  the  wound,  should  be  inserted  between  the  fat  and  aponeurotic 
layer  in  cases  where  there  has  been  much  manipulation  or  where  the 
adipose  tissue  is  thick.  The  skin  may  be  coaptated  with  the  Mitchell 
clamp,  buried  silver  wire  or  other  suture.  The  retention  sutures  are  of 
silkworm  gut.  Medium  catgut  is  used  for  the  lower  layers,  plain  in  the 
case  of  the  peritoneum  and  chromicized  for  the  muscle  and  aponeurosis. 
The  retention  sutures,  if  used,  are  employed  merely  to  support  the  wall 
until  the  dangers  of  vomiting  and  meteorism  are  passed  and  union  has 
begun. 

GRASER'S  OPERATION. 

Menge  was  very  much  opposed  to  cutting  into  the  anterior  sheath  of 
the  recti  muscles.  He  advised  incision  of  the  posterior  sheath,  so  as  to 
effect  the  release  and  suture  of  these  muscles  as  high  and  as  low  as  pos- 
sible. E.  Graser  performed  this  kind  of  operation  four  times  in  cases  of 
large  umbilical  and  abdominal  hernias,  with  most  excellent  results.  How- 
ever, the  operation  is  a  serious  one;  it  is  a  tedious  one,  and  the  numerous 
imbedded  sutures  favor  the  occurrence  of  sepsis. 

The  principal  incision  is  made  transversely  over  the  highest  point 
of  the  abdominal  tumor,  its  length  varying  from  35  to  50  centimeters.  The 
sac  is  opened,  adhesions  of  the  intestine  are  freed,  and  the  trimmed  part 
of  the  sac  is  brought  to  the  hernial  ring.  A  separation  of  the  sheaths  of 
the  recti  muscles  into  an  anterior  and  a  posterior  flap  is  absolutely  nec- 
essary. The  anterior  sheath  is  divided  transversely  as  far  as  the  external 
border  of  the  rectus  muscle,  often  widely  displaced  laterally,  and  then  the 
entire  aponeurotic  flap  is  lifted  up.  Where  a  separation  is  not  possible, 
the  commissure  of  the  rectus  sheath  is  to  be  split  along  the  inner  border, 
care  being  taken  to  avoid  injuring  the  anterior  la_ver.  Above  and  below, 
where  the  recti  muscles  approach  each  other  but  do  not  touch,  a  longi- 
tudinal incision  is  made,  near  the  linea  alba,  so  that  the  fibrous  structure 
of  this  remains  in  contact  as  a  stifle  ligamentous  layer. 

The  flap  having  been  prepared,  the  peeling  out  of  the  rectus  muscle 
is  effected,  the  loosening  being-  done  very  carefully  both  from  the  anterior 
and  the  posterior  sheaths,  with  preservation  of  the  nerves.  When  the 
loosening  is  completed,  the  suturing  of  the  omentum  is  proceeded  with, 
and  best  simultaneously  with  closure  of  the  posterior  sheath  of  the  rec- 
tus. On  account  of  the  tension,  stay  sutures  are  generally  necessary. 
Above  and  below  the  union  can  only  be  made  in  vertical  line  on  account 
of  the  linear  incision.  Transverse  seams  may  be  added  to  diminish  the 
gaping. 


PLATE  LV. 
IVIayo's  Operation  for  Umbilical  Hernia. 


RADICAL     CURE    OF    UMBILICAL     HERNIA  3I3 

Now  follows,  and  likewise  in  vertical  direction,  the  union  of  the 
rectus  muscles  by  interrupted  sutures,  some  of  which  are  passed  deeper ; 
others  above  these  draw  the  edges  somewhat  over  each  other.  The  edges 
of  the  anterior  aponeurosis  are  trimmed  and  approximated  by  a  right  solid 
row  of  interrupted  iodized  silk  or  catgut  sutures.  If  the  tissue  is  re- 
dundant, one  flap  can  be  pushed  under  the  other,  thus  doubling  the  line 
of  union. 

C.  A.  Wheaton,  of  St.  Paul,  advises  operation  in  all  cases  of  umbilical 
hernia,  no  matter  what  the  size  of  the  hernia,  and  also  advises  reducing 
the  body  weight  of  fleshy  patients  by  a  systematic  course  of  treatment 
carried  out  for  a  few  wrecks  before  the  operation  is  done. 

Terrier,  Czerny,  Reverdin,  and  others  removed  the  hernial  sac,  re- 
sected the  omentum,  reduced  the  contents  of  the  sac,  sutured  the  borders 
of  the  hernial  ring  in  layers,  and  closed  the  skin  by  a  separate  layer  of 
sutures.     The  results  were  not  very  satisfactory. 

Condamin  opened  the  abdominal  wall  at  the  periphery  of  the  hernia 
and  continued  the  incision  until  the  peritoneal  cavity  was  reached.  Thus 
the  sac,  superfluous  skin  and  umbilicus  were  removed  in  one  portion. 
Omphalectomy  and  closure  of  the  wound  in  separate  layers  as  in  an  or- 
dinary laparotomy  completed  the  operation. 

Gersuny  dissected  free  the  edges  of  the  recti  muscles,  uniting  them 
by  suture.  The  skin  wound  was  tamponnaded  with  gauze  and  allowed  to 
remain  open  for  a  few  days,  after  which  time  it  was  closed  by  superficial 
sutures. 

Champonniere  sutured  the  edges  of  the  aponeurosis  of  the  peritoneum, 
placing  a  second  and  sometimes  a  third  row  of  sutures  in  the  aponeurosis, 
— superposition  of  rows  of  sutures. 

V.  Pauchet  recommended  prolonged  fasting  before  operating  on  large 
hernias  in  obese  subjects.  He  laid 'down  the  following  regimen:  Warm 
or  cold  water  is  to  be  drunk  at  discretion  at  least  four  quarts  during  the 
twenty-four  hours,  either  pure  or  in  the  form  of  lemonade,  or  slightly 
salted  decoctions  of  herbs.  If  the  patient  is  moderately  active  or  con- 
tinues at  his  work,  an  ungarnished  salad  at  noon  and  an  apple  morning 
and  evening,  or  four  or  five  oranges  daily,  may  be  taken.  On  this  diet 
the  patient  is  reduced  to  his  proper  weight  in  six  weeks  or  three  months. 

HERNIAS  OPERATED  ON  BY  LAPAROTOMY. 

On  ten  occasions  I  operated  on  and  cured  femoral  liernias  b}'  the 
abdominal  route,  the  primarj^  indication  for  the  laparotomy  being  fibroids 
of  the  uterus  in  tvv'o  cases ;  ovarian  cysts  ir  two  cases ;  inguinal  hernia  in 
three  cases,  and  appendectomy  in  three  cases.  In  each  one  of  these  cases 
the  sac  was  turned  inside  out  and  cut  off.  The  interna)  aspect  of  the  crural 
canal  was  exposed  and  the  canal  closed  with  two  sutures  of  chromic  catgut 
passing  through  Pcupart's  ligament  and  the  periosteum  of  the  pubic  bone. 
The  peritoneum  was  then  sutured  in  such  a  manner  as  to  turn  the  raw  edges 
outward. 

In  treating  femoral  hernia  bv  the  abdominal  route,  the  technic  of  the 


314  R.\DICAL     CURE    OF     UMBILICAL     HERNIA 

operalion  is  greath'  facilitated  by  placing  the  patient  in  the  Trendelenbi'irg 
position. 

V\"hen  it  becomes  necessary  to  open  the  abdomen  of  an  individual  who 
has  a  femoral  hernia,  there  is  no  need  for  performing  any  of  the  special 
operations  for  this  condition. 

A  laparotomy  is  the  only  means  of  treating  epigastric,  certain  umbilical, 
ventral,  vesical,  lumbar,  and  urachal  hernias,  and  also  for  those  hernias, 
either  congenital  or  acquired,  that  occur  through  the  rectus  muscle,  linea 
alba,  and  linea  semilunaris. 

The  special  indication  for  laparotomy  is  the  occurrence  of  the  so-called 
internal  hernias,  such  as  (i)  diaphragmatic  hernia;  (2)  hernia  into  the 
duodeno-jejunal  fossa  (posterior  internal  hernia  of  Treitz)  ;  ('3)  Winslowian 
(a  true  internal  hernia  into  the  foramen  of  Winslow)  ;  (4)  hernia  into  the 
inter-sigmoid  fossa;  (5)  into  the  mesocolic  fossa;  (6)  omental  and  mesen- 
teric hernia;  (7)  pelvic  hernias — obturator,  sciatic,  vesico-rectal,  perineal, 
and  hernia  into  Douglas'  cul  de  sac. 


CHAPTER  VII. 

REPAIR  OF  LARGE  DEFECTS  IN  ABDOMINAL  WALL. 

A  number  of  operators  have  devised  methods  for  repairing  large  de- 
fects in  the  abdominal  wall  following  operations  for  hernia  and  abdominal 
sections  done  for  various  purposes.  Xotable  among  these  methods  are 
those  devised  b}^  Phelps,  Meyer  and  Bartlett,  in  which  a  metal  filigree  is 
employed.  Witzel  was  the  first  to  suggest  the  idea  of  embedding  in  the 
wound  a  ready-made  filigree.  He  drew  the  edges  of  the  wound  together 
as  much  as  possible  with  heavy  silver  sutures,  which  penetrated  muscles 
and  fascia ;  then,  after  these  had  been  tied,  he  ran  slender  wares  in  every 
direction  across  the  opening  which  remained. 

Willy  ]Meyer,  of  New  York,  used  a  network  consisting  of  wires 
crossing  at  right  angles  and  equidistant  from  one  another,  resembling 
the  ordinary  mosquito  netting.  In  the  Annals  of  Surgery,  November, 
1902,  he  reports  three  cases  in  which  a  silver  filigree  was  used  with  excel- 
lent results.  The  first  patient  was  a  man,  aged  55,  who  had  previously 
been  operated  for  strangulated  hernia.  For  several  years  the  defect  in 
the  abdominal  wall  was  left  unprotected  until  finally  a  large  ventral  hernia 
developed,  accompanied  by  severe  pain.  The  opening  was  closed  with  sil- 
ver wire  netting,  and  although  a  fistula  developed,  which  alternately  closed 
and  opened,  the  man  was  perfectly  able  to  atend  to  his  heavy  work.  The 
patient  died  two  years  after  the  operation  from  general  peritonitis  fol- 
lowing the  lifting  of  a  heavy  cake  of  ice  and  the  production  of  a  com- 
plete intestinal  obstruction  at  the  site  of  an  incomplete  obstruction  due  to 
manifold  old-standing  adhesions  between  coils  of  the  small  intestine.  The 
wire  netting  had  no  relation  to  the  trouble. 

The  second  patient,  a  woman  of  43,  following  a  laparotomy,  devel- 
oped a  large,  irreducible,  omento-intestinal  hernia,  the  aperture  being 
about  midway  between  the  symphysis  and  the  umbilicus.  Following  a 
first  unsuccessful  attempt  at  cure  of  the  hernia,  a  second  operation  was 
done  with  the  help  of  the  silver  ware  netting.  It  was  successful.  Sev- 
eral months  later  a  severe  traum.a  tore  the  continuous  wire  suture  causing 
one  of  the  corners  of  the  filigree  pad  to  come  loose. 

The  third  patient,  woman,  aged  31,  had  what  appeared  to  be  an  irre-. 
ducible,  inflamed  umbilical  omental  hernia.  It  was  finally  reduced  after 
the  inflammation  had  subsided  and  a  radical  operation  was  performed  with 
implantation  of  the  silver  filigree. 

Willard  Bartlett,  of  St.  Louis,  introduced  a  form -of  filigree  (Annals 
of  Surgery,  July,  1903)  vv^hich  depends  for  its  efficacy  on  the  fact  that 
all  but  one  of  its  wires  run  across  the  long  axis  of  the  scar  and  penetrate 
for  a  distance  of  one  or  two  inches  betv/een  the  tissue  lavers,  where  they 


3l6  REPAIR     OF     LARGE     DEFECTS     IN     ABDOMINAL     WALL 

are  firmly  anchored,  not  by  sutures,  hut  hy  newly- formed  scar  tissue  which 
Bartlett  says  fills  out  the  opening  of  each  loop  while  the  patient  is  in 
bed  after  the  operation.  He  purposely  bends  each  of  these  cross  wires  into 
the  form  of  a  loop  in  order  that  there  shah  be  no  sharp  irritating  ends 
anywhere,  and  he  lays  great  stress  on  the  fact  that  each  of  these  loops 
should  be  entirely  separated  at  the  free  end  from  its  neighbor.  Thus  the 
minimum  of  stiffening  is  imparted  to  the  tissues  by  the  single  longitudinal 
twist  which  binds  the  several  loops  together  in  the  median  line  of  the  con- 
trivance. The  last-named  wire  strand  appears  necessary  to  prevent  the 
possibility  of  a  hernia  between  two  of  the  cross  wires,  which  might  easily 
be  forced  slightly  apart  if  they  were  not  fastened  together  at  all. 

In  cases  that  allow  of  no  accurate  determination  beforehand,  as 
to  the  size  of  filigree  desired,  Bartlett  uses  a  net  which  difi^ers  slightly 
in  its  construction  from  that  just  described.  No  median  wire  twist  binds 
the  cross  loops  together ;  however,  Bartlett  compensates  for  this  by  sewing 
the  filigree  in  place  with  a  continuous  suture  of  fine  wire,  being  careful 
to  loop  the  suture  around  each  point  of  crossing  in  the  filigree. 

J.  Wiener,  Jr.  (Annals  of  Surgery,  April,  1906)  reports  seven  cases 
in  which  he  used  Bartlett's  filigree.  The  first  patient,  a  man,  aged  34, 
had  a  ventral  hernia.  The  gap  was  filled  in  with  silver  wire  sutures 
passed  from  side  to  side  so  as  to  m.ake  a  filigree.  Sixteen  months  after 
the  operation  there  had  been  no  recurrence  and  the  patient  was  perfectly 
comfortable.  The  second  patient,  a  man,  aged  30,  had  an  oblique  right 
inguinal  hernia  for  three  years  and  a  left  sided  hernia  for  one  year.  The 
wide  gap  was  bridged  over  by  a  continuous  suture  of  silver  wire  so  as  to 
make  a  sort  of  figure-of-eight  filigree.  The  operation  was  successful.  The 
third  patient,  a  man,  aged  53,  had  a  large  right  inguinal  hernia  which  re- 
curred after  operation.  A  silver  wire  filigree  was  sutured  over  the  inguinal 
canal,  and  the  superficial  fascia  and  skin  were  brought  together  with  in- 
terrupted sutures.  Death  occurred  on  the  sixth  day  and  was  undoubtedly 
due  to  the  fact  that  the  abdominal  cavity  could  not  accommodate  itself  to 
the  large  amount  of  intestines  which  had  been  in  the  sac. 

The  fourth  patient  was  a  man,  aged  t,/,  who  had  a  large  ventral  her- 
nia in  the  left  iliac  fossa  the  result  of  a  severe  trauma.  A  silver  wire 
filigree,  2x  2J/2  inches,  was  placed  between  the  peritoneum  and  the  trans- 
versalis  muscle ;  the  external  oblique  was  approximated  with  a  running 
suture  of  silver  wire  and  the  skin  with  silk.  The  man  made  a  perfect 
recovery.  The  fifth  patient,  a  woman,  aged  24,  had  a  large  ventral  her- 
nia following  appendectomy.  A  hernioplasty  was  done  with  resection  of 
gut  for  gangrene  and  the  abdomen  was  closed  with  silver  wire.  The  pa- 
tient recovered  and  has  been  doing  arduous  housework  sini„e  the  operation. 

The  sixth  patient,  woman,  aged  30,  had  a  large  umbilical  hernia  of 
five  years'  standing  which  became  irreducible.  The  sac  was  filled  with 
omentum  and  one  loop  of  small  intestine.  The  intestine  was  replaced  and 
the  omentum  resected.  Sutures  of  silver  wire  almost  completely  obliter- 
ated the  diastasis  at  the  neck  of  the  sac.  Three  months  later,  during  a 
severe  attack  of  bronchitis,  the  patient  developed  a  small  hernia  below  the 


REPAIR     OF     LARGE     DEFECTS     IN     AEDO:SIIN.AL     WALL  317 

umbilicus.     Meyer  is  convinced  that  if  lie  had  put  in  a  filigree  in  addition 
to  the  wire  sutures  this  recurrence  would  not  have  happened. 

The  last  patient,  a  woman,  aged  27,  had  a  tumor  of  the  rectus  muscle 
removed.  A  filigree  was  placed  in  the  depth  of  the  v/ound  and  a  second 
filigree  through  the  oblique  muscles.     Recovery  was  uneventful. 


CHAPTER  VIII. 

DIAPHRAGMATIC  HERNIA. 

Having  made  the  diagnosis  of  diaphragmaiic  hernia,  abdominal  section 
through  the  left  upper  half  of  the  rectus  muscle  should  be  undertaken  at 
once,  except  when  the  hernia  is  of  the  congenital  variety  and  occurs  earl}' 
in  life.  S^miptoms  of  intestinal  strangulation  are  often  the  first  indication 
cf  the  existence  of  a  diaphragmatic  hernia,  and  the  cause  of  these  manifes- 
tations often  is  not  discovered  until  the  abdomen  has  been  opened  or  durmg 
an  autops3^ 

As  a  matter  of  fact,  the  presence  of  a  diaphragmatic  hernia  seldom  is 
discovered  during  life.  In  but  seven  of  266  cases  reviewed  by  Lachner  was 
the  diagnosis  made  ante-mortem.  Maragliano  also  reported  a  case  (1897) 
in  which  the  diagnosis  was  made  during  life.  In  this  instance  the  hernia 
developed  suddenly  during  a  fit  of  coughing.  Air  was  pumped  into  the  rec- 
tum, and  it  was  noticed  that  thereby  the  size  of  the  left  side  of  the  chest 
v/as  increased  and  palpation  elicited  a  tympanitic  note.  With  each  insuffla- 
tion a  sound  was  heard  in  the  fifth  intercostal  space.  Water  was  then  in- 
jected and  it  produced  an  area  of  dullness  where  there  had  been  tympany 
before. 

The  abdomen  having  been  opened,  a  sandbag  is  placed  beneath  the 
shoulder-blades  so  as  to  tilt  the  diaphragm.  The  intestines,  stomach  or 
omentum,  as  the  case  may  be,  are  drawn  out  from  the  thoracic  cavity  and 
the  opening  in  the  diaphragm  is  sutured.  Rochard,  Schwartz,  Perman, 
Treves,  and  others  advise  attacking  the  hernia  Lhrough  the  pleural  cavity 
by  means  of  a  resection  of  the  costal  arch  of  the  ninth  rib.  If  the  hernia  is 
incarcerated,  I  believe  that  the  thoracic  route  is  the  preferable  one,  but  in 
cases  where  the  hernia  is  inflamed,  ulcerated,  strangulated,  or  gangrenous, 
v/hen  a  resection  of  the  bowel  must  be  done,  the  thoracic  route  insures  less 
tendency  to  infect  the  peritoneal  cavity.  The  bowel  is  clamped  ofi^  readily 
above  the  diaphragm,  and  the  resection  is  done  speedily.  ;\n  end-to-end 
anastomosis  completes  the  operation.  The  pleural  cavity  must  be  drained 
freely. 

Before  undertaking  the  operation  for  the  cure  of  a  diaphragmatic  hernia, 
it  is  absolutely  essential  that  the  stomach  be  v/ashed  out,  because  otherwise 
there  exists  the  possibility  of  the  patient  becoming  drowned  in  his  own 
vomitus.  This  precaution  should  never  be  neglected  in  any  case  of  intestinal 
obstruction. 

F.  W.  McRae  (Trans.  South.  Sitrg.  and  Gyn.  Assoc,  1894)  reports  the 
case  of  a  man  who  was  stabbed  in  three  places,  in  the  back  below  the 
scapula,  and  in  the  left  side,  four  and  one-half  inches  from  the  axillary 
line  between  the  fifth  and  sixth  ribs,  three  and  one-half  inches   from  the 


PLATE  LVI. 

Large  Umbilical  and  Post-operative  Ventral  Hernias. 
(Author's  Case.) 


DIAPHRAGMATIC     HERNIA  32 1 

nipple.  The  third  wound  passed  through  the  tissues  and  entered  the  thoracic 
cavity.  The  patient  was  unable  to  lie  down  on  account  of  the  pain  in  his 
side.  The  wound  was  closed  carefully.  The  patient  recovered  from  the 
injury,  but  the  pain  continued,  and  finally,  eight  months  after  the  injury, 
hiccough  and  stercoraceous  vomiting  set  in.  To  the  right  of  the  wound  there 
was  an  enlargement  about  the  size  of  a  small  hen's  egg.  The  diagnosis 
made  was  that  of  hernia  or  telescoping  of  the  bowel.  At  the  operation  the 
opening  in  the  diaphragm  was  readily  located,  and  the  colon  was  found 
completely  strangulated.  McRae  found  in  the  thoracic  cavity  the  entire 
stomach  and  greater  omentum,  about  one  foot  of  the  small  intestme,  and 
the  whole  of  the  transverse  and  a  part  of  the  descending  colon.  All  these 
structures  were  gangrenous.  The  wound  was  closed.  The  patient  died' 
about  seven  hours  afterwards.  The  strangulation  in  the  case  had  existed  for 
five  days,  and  McRae  is  of  the  opinion  that  an  early  operation  might  have 
served  to  prolong  the  life  of  the  patient. 

A  second  case  seen  b\  McRae  was  a  woman,  ^y  years  old,  who  was 
taken  sick  suddenly  with  severe  pain  in  the  left  lower  quadrant  of  the 
abdomen.  The  abdomen  v,'as  swollen  and  tender.  The  temperature  was 
elevated  slightly.  Repeated  enemata  were  given,  without  results.  On  the 
third  day  the  patient  vomited  mucus  and  fecal  matter.  At  the  operation 
part  of  the  large  intestine  and  a  portion  of  the  stomach  were  found  pro- 
truding through  the  hernial  opening  in  the  diaphragm  on  the  left  side. 
Breathing  became  very  poor,  as  soon  as  air  was  admitted  into  the  thorax, 
and  mucus,  mixed  with  a  little  fecal  matter,  began  to  run  from  the  nose 
and  mouth.  There  was  general  peritonitis.  During  the  closure  of  the  abdo- 
men the  patient  vomited  a  large  quantity  of  matter,  and  "drowned." 

Hale  and  Goodhart  (Trans.  Lon.  Clin.  Soc,  1892)  report  a  case  of 
diaphragmatic  hernia  which  was  diagnosed  as  cancer  of  the  stomach,  and 
in  which  death  was  caused  by  vomiting.  The  patient,  a  man,  aged  49,  the 
subject  of  a  double  inguinal  hernia,  complained  of  bringing  up  raouthfuls  of 
a  dark,  clear  mucus,  and  about  every  week  or  ten  days  he  vomited  enormous 
quantities  of  fluid  of  a  similar  character.  He  had  a  sensation  of  heat  and 
pain  at  the  ensiform  cartilage.  Bowels  were  obstinately  confined.  He  had 
been  losing  flesh  for  some  time.  A  tympanitic  resonance  was  found  pos- 
teriorly as  high  as  the  middle  of  the  left  scapula.  There  was  retraction  of 
the  abdomen.  The  post-mortem  revealed  a  piece  of  the  splenic  flexure  of 
the  colon  entering  the  thorax  through  an  aperture  between  the  crura  of 
the  diaphragm  beneath  the  liver.  A  portion  of  the  stomach  and  transverse 
colon  also  entered  through  this  opening.  The  stomach  was  enormously 
dilated.  A  large  portion  of  it  was  free  in  the  bottom  of  the  left  pleura.  The 
sac  contained  two-thirds  of  the  stomach,  a  large  portion  of  the  transverse 
colon,  the  lesser  omentum,  and  the  greater  part  of  the  pancreas  and  the 
duodenum. 

In  1900,  Funck-Brentano  reported  a  case  of  congenital  diaphragmatic 
hernia  which  was  discovered  at  the  post-mortem.  The  patient  died  from 
convulsions  when  fifty-five  days  old.  There  was  a  free  communication  be- 
tween the  thoracic  and  abdominal  cavities.     The  left  pleural  cavity  was  oc- 


322 


DIAPHRAGMATIC     HERNIA 


'cupied  by  the  spleen,  and  a  large  part  of  both  the  large  and  small  intestines. 
The  lung  on  that  side  was  compressed  to  about  the  size  of  a  bean,  and  the 
heart  was  displaced  to  the  right  of  the  medium  line. 

I.  A.  Abt  (Chicago  Medical  Recorder,  August,  1900)  also  reports  a 
case  of  congenital  diaphragmatic  hernia,  occurring  in  a  child  born  dead. 
The  diaphragm  on  the  left  side  was  almost  completely  absent,  the  left 
thoracic  cavity  being  occupied  in  large  part  by  the  liver.  The  greater  cur- 
vature of  the  stomach  occupied  the  space  normally  filled  by  the  apex  of  the 
luno-  and  a  considerable  portion  of  both  the  small  and  large  intestines  oc- 
cupied  the  thoracic  cavity. 

Walker  (Internat.  Jour,  of  Surg.,  September,  1900)  reports  a  case  of 
diaphragmatic  hernia  occurring  in  a  man,  aged  29,  who  was  mjured  by  a 
falling  tree.  There  was  severe  pain  in  the  left  chest,  which  was  aggravated 
bv  coughing  and  deep  inspiration.  Respirations  were  shallow  and  rapid; 
pulse,  145  ;  bowels  could  not  be  opened  and  fecal  vomiting  ensued.  The 
abdomen  became  distended.  Examination  of  the  left  chest  showed  dimin- 
ished expansion,  amphoric  breathing  and  a  tympanitic  note  at  the  base  of 
the  lung ;  succussion  sounds  were  heard  when  the  patient  was  shaken.  The 
apex  of  the  heart  was  displaced  two  inches  to  the  right,  and  the  seventh 
and  eighth  ribs  were  fractured  on  the  left  side.  At  the  operation  a  piece  of 
small  intestine  was  found  firmly  held  in  a  rent  in  the  diaphragm.  The  bowel 
was  withdrawn  and  the  opening  partially  closed.     Patient  recovered. 

Klaggs  (London  Lancet,  Aug.  6,  1904)  collected  53  cases  of  diaphrag- 
matic hernia  of  the  stomach,  including  three  of  his  own.  Of  the  whole 
number,  20  were  congenital  21  were  traumatic,  and  12  were  acquired.  The 
symptoms  varied  and  were  irregular.  Usually  there  was  disturbance  of 
respiration  and  digestion,  wuth  signs  of  obstruction  and  strangulation,  and 
especially  tetanus.     The  physical  signs  were  indefinite. 

Stomach  and  intestinal  murmurs  w^ere  heard  in  the  thorax.  The  heart 
was  displaced.  A  murmur  was  often  elicited  by  passing  air  into  the  stomach. 
Other  signs  were  interference  with  pulmonary  murmur  and  resonance; 
alteration  in  the  shape  of  the  thorax ;  sanguine  expectoration  and  inability 
to  lie  on  the  right  side.  The  lesions  found  at  autopsy  were  adhesions,  ulcer, 
dilatation  and  strangulation  of  the  stomach,  and  obstruction  caused  by  vol- 
vulus of  stomach  or  torsion  of  lesser  omentum. 

H.  B.  G.  Newham  (Lond.  Lancet,  Dec.  24,  1904)  saw  a  man  soon  after 
a  fall  of  thirty  feet  which  had  caused  extensive  bruising  but  no  apparent 
fracture.  The  stomach  and  part  of  the  colon  occupied  the  left  half  of  the 
thorax,  displacing  the  heart  to  the  right.  The  tear  in  the  diaphragm  was 
supposed  to  have  been  produced  by  sudden  anl  violent  muscular  contraction. 
The  patient  survived  two  days  in  spite  of  much  precordial  and  abdominal 
pain. 

In  dealing  with  this  class  of  hernias,  the  operator  must  bear  in  mind 
that  over  ninety  per  cent,  of  them  have  no  sac.  Grosser  studied  433  cases, 
only  40  of  which  had  a  sac.  They  are,  therefore,  either  true  or  false,  con- 
genital or  acquired.  The  whole  left  half  of  die  diaphragm  may  be  thinned 
out  and  protrude  upward,  giving  rise  to  symptoms  and  signs  that  simulate 


DIAPHRAGMATIC     HERNIA  ^2^ 

a  hernia  of  the  diaphragm.  This  condition  was  designated  by  Cruveilhier 
and  Thoma  diaphragmatic  eventration. 

In  1898,  at  the  Chicago  Post-Graduate  Hospital,  I  was  induced  to  ex- 
pose the  diaphragm  of  a  young  man  for  a  supposed  hernia  of  that  muscle 
on  the  left  side.  This  young  man  had  what  has  been  termed  the  operation 
habit.  His  appendix  had  been  removed,  his  gall  bladder  had  been  explored, 
the  right  kidney  had  been  drained,  and  an  exploratory  laparotomy  had  been 
done  on  him.  I  operated  on  him  for  a  post-operative  hernia  following  the 
appendectomy.  Nine  months  afterward  he  was  referred  to  me  again  for 
this  supposed  diaphragmatic  hernia.  Knowing  of  his  habit,  I  observed  him 
for  about  three  days,  and  then  came  to  the  conclusion  that  he  did  not  have 
a  hernia. 

Three  days  afterward  he  appeared  at  a  medical  meeting  and  the  phy- 
sician in  charge  made  a  positive  diagnosis  of  a  left-sided  diaphragmatic 
hernia.  The  patient  was  referred  to  me  for  operation.  I  explored  the  entire 
lower  surface  of  the  diaphragm  and  demonstrated  that  no  hernia  existed, 
but  that  the  diaphragm  was  very  much  thinned  and  arched  mucli  higher 
than  normal.  The  patient  left  the  hospital  two  weeks  afterward  in  good 
condition,  having  been  relieved  of  many  of  his  supposed  symptoms. 

I  kept  this  young  man  under  observation  for  a  number  of  years.  He 
died  in  a  neighboring  city  of  general  peritonitis  following  an  operation 
done  for  a  supposed  intestinal  obstruction.  I  was  informed  that  a  long  and 
tedious  operation  failed  to  reveal  any  obstruction. 

Early  in  my  professional  career  I  delivered  a  woman  of  a  fully  developed 
boy.  The  next  day  the  infant  began  to  vomit,  and  became  bloated.  He  died 
on  the  fifth  day,  with  symptoms  of  obstruction  of  the  bowel.  The  post- 
mortem revealed  a  loop  of  jejunum  passing  through  the  central  tendon  of 
the  diaphragm. 

The  surgeon  should  familiarize  himself  with  the  places  in  the  diaphragm 
where  hernias  have  been  found.  Irrespective  of  gross  congenital  deficiencies, 
and  also  apart  from  injuries  of  the  diaphragm,  hernial  openings  have  been 
demonstrated  in  the  following  places:  (i)  Central  tendon  (most  frequent)  ; 
(2)  muscular  portion  (posterior  inferior);  (3)  sterno-costal  fissures;  (4) 
esophageal  opening;  (5)  lumbo-costal  fissures ;  {6)  sympathetic  trunk  open- 
ing; (7)  aortic  opening;  (8)  psoas  muscle  opening,  and  (9)  the  opening 
through  which  the  quadratus  lumborum  muscle  passes. 

A  diaphragmatic  enterocele  is  shown  in  Fig.  10,  and  an  epiplocele 
in  the  pericardium  is  shown  in  Fig.  9. 

The  results  following  operation  for  diaphragmatic  hernia  are  not  very 
encouraging  when  strangulation  has  occurred.  The  mortality  is  about  95 
per  cent.  It  is  said  that  cases  have  been  operated  on  successfully  by  Hum- 
bert, Leisrink,  Postempski    and  Mikulicz. 


CHAPTER  IX. 

INTERNAL  AND  INFERIOR  HERNIAS. 

HERNIA  INTO  DTJODENO-JEJUNAL  FOSSA. 

Hernia  into  tlie  fossa  of  Treitz  (duodeno- jejunal)  is  an  indication  for 
the  performance  of  an  abdominal  section.  There  are  two  varieties  of  this 
hernia:  (a)  Right,  and  (b)  Left.  In  the  former  variety  the  superior  mesen- 
teric artery  lies  in  front  of  the  sac,  and  in  the  latter  the  superior  mesenteric 
vein  is  in  front  of  the  sac.  The  incision  through  the  abdominal  wall  should 
be  made  a  little   above  and  to  the  left  of  the  umbilicus. 

Although  these  hernias  are  always  twisted,  they  are  not  difficult  to 
liberate,  except  when  adhesions  have  formed  or  strangulation  has  occurred. 
Then  the  edges  of  the  ring  may  be  nicked  carefully  and  the  opening  dilated. 

After  withdrawing  the  intestines  into  the  peritoneal  cavity,  a  few- 
stitches  of  silk  or  catgut  should  be  inserted  to  obliterate  the  ring  and  pre- 
vent a  recurrence.  The  sac  may  be  opened,  if  necessary,  to  facilitate  the 
reduction  of  the  hernia. 

This  form  of  hernia  is  comparatively  rare,  but  quite  a  number  of  in- 
stances are  recorded  in  the  literature,  and  the  following  citations  will  serve 
to  explain  the  nature  of  these  hernias,  the  method  of  treatment  that  is  usually 
adopted  to  correct  them,  and  the  results  that  may  be  obtained.  It  would 
be  useless  to  cite  all  the  cases  that  have  been  reported. 

Bingel  (Archiv  f.  Pathologische  Anatomic,  No.  i,  1902)  reports  a  case 
of  hernia  into  the  fossa  duodeno-jejunalis  occurring  in  a  woman,  aged  28 
years,  which  proved  fatal  in  twenty  hours.  At  the  autopsy  the  abdomen 
contained  a  large  quantity  of  blood-stained  fluid  and  the  coils  of  the  intes- 
tine on  the  right  side  were  distended,  infiltrated  with  blood  and  covered 
with  a  thin,  fibrous  exudate.  The  left  side  of  the  abdomen  was  occupied 
by  a  tumor  reaching  from  the  diaphragm  to  the  pelvis.  This  tumor  proved 
to  be  a  large  peritoneal  sac  containing  enormous  coils  of  intestine  and  their 
mesentery.  Strangulation  was  brought  about  apparently  by  the  escape  of 
a  coil  of  intestine  from,  the  sac. 

L.  L.  McArthur  (Surg.,  Gyn.  and  Obs.,  January,  1906)  cites  a  case  of 
hernia  in  the  fossa  of  Treitz  consisting  of  an  incarcerated  loop  of  jejunum 
of  which  an  accurate  diagnosis  couM  not  be  made  before  laparotomy,  and 
then  only  after  a  most  exhaustive  search  through  the  abdom.en.  After  a 
careful  study  of  the  history  of  the  case  it  appeared  probable  that  there 
existed  an  acute  intestinal  obstruction,  which  might  be  due  either  to  a 
mechanical  or  to  an  infective  inflammatory  cause.  In  favor  of  the  mechani- 
cal nature  of  the  obstruction  was  the  somewhat  gradual  onset  of  the  ob- 
structive symptoms,  without  high  fever,  and  with  the  appearance  of  blood 


PLATE  LA'II. 

Blake's   Operation   for   Umbilical   Hernia   Completed. 
(Author's  Case.) 


INTERNAI.     AND     IXPF,RTOR     HERM.'vS  32/ 

and  mucus  in  the  stools  ;  the  blood  count,  while  elevated,  not  being  high 
enough  to  be  convincing  as  to  the  presence  of  pus.  Because  of  the  tender- 
ness over  the  whole  abdomen,  the  sudden  sharp  exacerbation  of  the  pains 
on  the  second  day,  and  some  rise  in  temperature,  attention  was  directed 
to  the  appendix,  but  without  other  corroborative  signs.  Following  the  evis- 
cerations  in  the  endeavor  to  find  the  point  of  obstruction,  almost  the  entire 
small  intestine  was  removed  from. the  abdomen  before  a  small  loop  was 
found  which  led  to  the  discovery  of  the  cause  of  the  trouble.  The  patient 
made  an  uneventful  recovery. 

Two  cases  of  left  duodenal  hernia  are  reported  by  L.  Freeman  (Trans. 
Am.  Surg.  Assn.,  1903). 

In  the  case  of  one  of  these  hernias  the  sac  contained  the  entire  small 
intestine,  the  cecum,  and  a  portion  of  the  colon,  which  was  strangulated. 
The  patient,  a  man,  aged  47,  following  an  attack  of  diarrhea  lasting  three 
weeks,  developed  a  severe  ileus,  with  the  usual  symptoms  of  acute  intestinal 
obstruction.  On  opening  the  abdomen,  the  cavity  was  occupied  by  an  im- 
mense tympanitic  tumor,  resembling  an  ovarian  cyst.  The  small  intestine 
could  not  be  seen,  but  the  colon  was  felt  below  and  to  the  right  side.  The 
sac  was  opened,  and  then  was  found  the  entire  small  intestine,  together 
with  the  cecum  and  some  six  or  eight  inches  of  the  adjacent  colon.  There 
was  also  considerable  foul  and  bloody  serous  fluid.  In  attempting  to  relieve 
the  condition,  it  was  necessary  to  resect  the  cecum,  which  was  gangrenous, 
together  with  some  six  inches  of  the  large  intestine  and  a  considerable  por- 
tion of  the  small  bowel. 

The  patient's  resisting  powers  were  so  poor  and  the  operation  was  so 
complicated  and  extended,  that  death  resulted.  The  entire  colon  lay  in  folds 
on  the  right  side  of  the  abdomen — a  congenital  condition. 

The  second  case  was  seen  at  autopsy.  The  patient  died  of  gangrene  of 
the  small  intestine,  accompanied  by  a  severe  hemorrhage  arising  from 
thrombosis  of  the  mesenteric  and  portal  veins.  The  patient  had  been  subject 
to  indigestion  and  occasionally  experienced  slight  pains  and  uneasiness  in 
the  abdomen.  The  sac  filled  the  entire  left  side  of  the  abdominal  cavity, 
and  was  well  over  to  the  right  of  the  median  line.  It  contained  all  but  six 
inches  of  the  small  intestine,  the  transverse  and  descending  colon  being 
spread  out  on  its  upper  and  left  outer  surface,  lea'ving  the  cecum,  colon  and 
sigmoid  in  their  normal  position.  The  mouth  of  the  sac  was  round  and 
smooth,  and  easily  admitted  three  fingers.  From  it  emerged  the  lower  end 
of  the  ileum  to  join  the  cecum  in  the  right  iliac  fossa.  The  opening  was  just 
to  the  right  of  the  vertebral  column,  on  a  level  with  the  crest  of  the  ileum 
and  toward  the  dorsal  and  inferior  portion  of  the  sac.  There  was  no  stran- 
gulation of  the  bowel  or  mesentery. 

In  December,  1906,  I  had  a  similar  case  in  private  practice.  The  patient 
had  not  been  well  for  a  number  of  years,  but  complained  most  of  recurrent 
attacks  of  pain  over  the  region  of  the  gall  bladder.  She  said  that  she  felt 
as  though  something  was  slipping  away  behind  the  stomach.  Inspection  of 
the  abdomen  was  negative.  Palpation  elicited  tenderness  over  the'  gall 
bladder  and  also  over  the  appendix.     The  gall  bladder  was  enlarged.     On 


328  INTERNAL     AND     INFERIOR     HERNIAS 

the  whole  the  physical  examination  did  not  furnish  much  evidence  on  which 
a  diagnosis   could   be  based. 

I  made  an  incision  through  the  right  rectus  muscle,  exposing  the  region 
of  the  gall  bladder  and  the  hepatic  flexure  of  the  colon.  The  gall  bladder 
was  adherent  to  the  right  upper  border  of  the  great  omentum,  which  in 
turn  was  adherent  to  the  lesser  curvature  of  the  stomach.  To  the  right  of 
the  bladder  was  a  Riedel  lobe,  extending  two  and  a  half  inches  below  the 
gall  bladder.  On  separating  the  adhesions  between  the  stomach,  gall  blad- 
der and  omentum,  a  knuckle  of  bowel  was  felt  to  protrude  above  the  lesser 
curvature  of  the  stomach.  It  could  be  pushed  back  behind  the  stomach,  but 
would  return  immediately.  On  passing  two  fingers  through  the  foramen 
of  Winslow,  it  appeared  to  be  blocked  by  a  resilient  mass,  which  I  took  to 
be  a  hernia.  I  withdrew  the  great  omentum  and  transverse  bowel  out  of 
the  wound,  disclosing  a  loop  of  the  upper  portion  of  the  jejunum,  extending 
behind  the  stomach  above  the  duodenum  into  the  lesser  cavity  of  the  peri- 
toneum. The  bowel  was  not  strangxilated,  which  accounted  for  the  feeling 
described  by  the  patient  of  something  slipping  away  from  behind  the  stom- 
ach. The  sac  of  the  hernia  consisted  of  the  posterior  layer  of  the  transverse 
meso-colon.    The  mouth  of  the  sac  easily  admitted  two  fingers. 

I  pulled  the  sac  out  and  inserted  a  circular  suture  in  such  a  manner  as 
to  pucker  up  the  sac  on  itself,  thus  obliterating  the  cavity  of  the  sac,  as 
well  as  its  mouth. 

A  short  time  ago  Dr.  H.  W.  Gentles  referred  a  case  of  this  kind  to  me 
for  operation.  On  opening  the  abdomen  I  found  a  perforation  of  an  ulcer 
of  the  stomach  near  the  pylorus  on  its  anterior  surface,  and  a  hard  mass 
near  the  pylorus  which  was  thought  to  be  a  carcinoma.  (Evidently  not  the 
case  according  to  later  history.)  On  attempting  to  do  a  gastro-enterostom}^ 
the  bowel  was  found  to  be  congested  and  I  also  discovered  a  left  complete 
hernia  of  the  small  intestine  through  the  jejunal  fossa.  The  hernia  was  re- 
duced and  the  opening  in  the  stomach  was  closed  by  a  circular  suture  and 
strengthened  b_v  sewing  the  falciform  ligament  as  a  flap  over  the  seat  of 
perforation.  The  patient's  condition  did  not  warrant  performing  a  gastro- 
enterostomy.    He  made  an  uneventful  recovery. 

WmSLOWIAN  HERNIA. 

In  this  form  of  hernia  the  bowel  passes  through  the  foramen  of  Wins- 
low  into  the  lesser  sac  of  the  peritoneum.  The  hernia  may  be  composed  of 
small  bowel  (Treitz),  transverse  colon  (Majoli),  cecum,  or  the  entire 
ascending  colon  and  a  part  of  the  transverse  colon  (Treves).  My  own  ex- 
perience with  this  class  of  hernias  being  iiii,  I  cannot  do  better  than  extract 
from  a  recent  article  by  Faure  {Bulletin  ct  Mem.  de  la  Soc.  dc  Chir.  de 
Paris,  No.  12,  1906)  who,  in  a  report  on  a  case  of  intestinal  strangulation 
at  the  foramen  of  Winslow,  communicated  by  Jcanbrau  and  Riche,  gives 
an  instructive  review  of  the  diagnostic  and  therapeutic  aspects  of  this  rare 
form  O'f  internal  hernia.  In  three-fourths  of  the  recorded  cases  the  stran- 
gulated mass  consisted  of  small  intestine ;  and  in  the  remaining  fourth  of 
transverse  colon  which,  it  has  been   found,  mav  drae  with   the  ascendiuir 


INTERNAL     AND     INFKRIOR     ITERNIAS  329 

colon  and  even  the  cecum,  which  extension,  however,  is  hardly  possible, 
except  in  connexion  with  certain  arrests  of  development,  and  with  per- 
sistence of  a  mesentery  common  to  both  small  and  large  intestine.  In  two 
cases  the  great  omentum  formed  part  of  the  herniated  mass.  The  clinical 
phenomena  are  those  of  intestinal  obstruction  with  epigastric  or  umbilical 
pain.  The  sole  really  important  sA-mptom  in  regard  to  the  diagnosis  of  the 
localization  of  the  obstruction  is  the  presence  of  a  swelling  in  these  re- 
gions. Hitherto,  Faure  points  out,  a  precise  diagnosis  has  never  been  made 
before  the  performance  of  laparotomy,  and,  it  is  added,  it  has  often  been 
found  difficult  even  after  exposure  of  the  abdominal  contents. 

Attention  is  directed  to  the  anatomical  researches  of  Jeanbrau  and  Riche, 
made  with  the  view  of  devising  some  effectual  method  of  relieving,  by  in- 
cision of  the  margin  of  the  foramen  of  Winslow,  the  intestinal  constriction. 
It  has  hitherto  been  assumed  that  the  numerous  difficulties  in  affording  such 
direct  relief  are  insuperable,  as  incision  of  the  margin  of  the  foramen  is  ren- 
dered impracticable  by  the  contiguity  of  the  vena  cava  behind,  of  the  portal 
vein  in  front  and  on  the  left,  of  the  common  bile  duct  in  front  and  on  the 
right,  and  the  Spigelian  lobe  above.  Jeanbrau  and  Riche  have  suggested  a 
method  of  dilating  the  foramen  by  attacking  its  lower  boundary  in  the  inter- 
space betw^een  the  vena  cava  and  the  portal  vein.  Faure,  regarding  the  pro- 
cedure of  these  surgeons  as  complicated,  dangerous,  and  ineffectual,  suggests 
one  which,  though  simple  in  theory,  is  not  unlikely  in  its  practical  application 
to  be  found  very  difficult.  He  proposes  to  incise  the  peritoneum  along  the 
descending  portion  of  the  duodenum  to  the  level  where  the  membrane  passes 
from  the  posterior  abdominal  wall  to  the  second  portion  of  this  intestine. 
By  means  of  the  finger  introduced  through  this  incision  the  vena  cava  can 
be  separated  from  the  duodenum,  the  head  of  the  pancreas,  and  the  portal 
vein,  and  the  inferior  margin  of  the  foramen  of  Winslow  be  thus  relaxed. 
If  in  a  supposed  case  of  strangulated  hernia  through  the  foramen  of  Wins- 
low, and,  indeed,  in  other  varieties  of  internal  strangulation,  the  patient 
be  in  an  alarming  condition,  and  the  intestine  much  distended,  Faure  would 
abstain  from  prolonged  exploration  and  free  handling  of  the  abdominal 
viscera,  and  would  establish  a  false  anus  above  and  as  close  as  possible  to 
the  umbilicus.  If  the  patient  recovered,  a  second  operation,  should  such 
be  required,  could  be  performed  under  much  more  favorable  conditions  for 
the  removal  of  the  obstacle  and  the  reduction  of  the  herniated  intestine. 
Such  procedure,  though  less  brilliant,  would,  it  is  argued,  be  more  success- 
ful than  that  proposed  by  Jeanbrau  and  Riche  of  making  an  incision  in  the 
wall  of  the  distended  intestine  for  the  discharge  of  its  contents,  and  then 
proceeding  to  explore  and,  if  possible,  to  dilate,  tlie  seat  of  the  constriction. 

{Rev.  de  Chir.,  XXVI,  No.  5)  contributes  an  article  based  on  personal 
clinical  experience  in  one  instance,  and  eighteen  cases  found  m  the  litera- 
ture. 

When  the  patient  is  examined  soon  after  the  occurrence  of  the  hernia, 
a  round,  circumscribed  tumor  is  noticed  in  the  epigastrium  or  at  the  um- 
bilicus, but  it  soon  blends  into  the  increasing  general  distension  of  the  entire 
abdomen.     This  early  tumefaction  is  important  for  the  diagnosis.     It  may 


330  INTERNAL     AND     INFERIOR     HERNIAS 

be  directly  in  the  center  or  more  toward  the  right,  and  its  center  may  co- 
incide with  the  umbihcus  or  lie  considerably  above  it,  but  always  below  the 
costal  arch.  In  none  of  the  cases  on  record  was  the  trouble  correctly  diag- 
nosed. In  some  it  was  overlooked  even  at  the  laparotomy.  The  small  in- 
testine is  generally  involved.  The  stomach  is  forced  forward  and  the  af- 
ferent loops  of  intestine  are  distended  and  held  immovable  under  the  liver, 
high  up  to  the  right.  No  hernial  sac  is  visible  except  in  the  rare  cases  in 
which  the  intestine  has  slipped  between  the  two  sheets  of  the  great  omen- 
tum. When  the  finger  is  able  to  trace  the  course  of  the  incarcerated  in- 
testine, the  pulsations  of  the  large  hepatic  artery  can  be  perceived.  In  the 
II  cases  in  which  an  operation  was  undertaken  it  proved  to  be  too  late  to 
save  the  patient  in  all  but  four  instances.  An  incision  into  the  intestine 
should  be  made  to  evacuate  it,  after  which  reduction  of  the  hernia  is  easy. 
There  is  a  sheet  of  loose  cellular  tissue,  between  the  vena  "cava  and  the 
duodenum,  through  which  it  is  easy  to  expose  the  lower  part  of  the  fora- 
men of  Winslow  after  incising  the  anterior  sheet  of  the  lesser  omentum 
over  the  upper  duodenum,  parallel  to  its  longitudinal  axis. 

Delkeskamp  (Beitr.  z.  Klin.  Chir.,  XLVII,  No.  2)  relates  the  par- 
ticulars of  a  case  of  intra-abdominal  hernia  through  the  foramen  of  Wins- 
low.  Immediately  after  a  normal  child-birth  in  a  woman,  aged  22,  signs  of 
intestinal  obstruction  developed,  the  symptoms  growing  progressively  worse. 
The  abdomen  was  opened  on  the  seventh  day  after  delivery,  and  the  hernia 
was  reduced  without  much  difficulty. 

INTERSIGMOID  HEENIA   (POSTERIOR). 

The  intersigmoid  fossa  is  not  present  always.  Treves  found  it  in  52 
per  cent,  of  100  bodies  examined.  The  fossa  is  located  over  the  bifurcation 
of  the  left  iliac  vessels,  and  the  sigmoid  artery  lies  above  and  to  the  right 
side  of  it.     The  fossa  extends  upward  along  the  left  ureter. 

According  to  Treves,  only  4  cases  of  hernia  into  the  intersigmoid  fossa 
were  reported  up  to  1899.  Three  of  these  were  strangulated  and  proved 
fatal.  The  only  treatment  to  be  adopted  is  abdominal  section,  and  this,  too, 
affords  the  only  means  of  making  a  diagnosis  of  this  condition. 

Fowler,  in  his  Textbook  on  Surgery,  quotes  Jonnesco  as  saying  that 
a  hernia  in  this  situation  has  been  observed  only  twice.  This  statement  does 
not  agree  with  that  made  by  Treves. 

MESOCOnC  HERNIA. 

A  sharp  line  of  differentiation  must  be  drawn  between  intra-abdominal 
protrusions  of  the  intestines  and  internal  hernias.  A  loop  of  bowel  pro- 
truding through  a  slit  in  the  mesentery  or  omentum  cannot  be  considered 
a  hernia  unless  there  is  a  sac.  An  exploratory  laparotomy  must  be  done 
in  order  to  make  a  diagnosis,  and  also  to  carry  out  proper  treatment. 

Peacock,  of  London,  England,  reported  two  cases  of  mesocolic  hernia, 
one  occurring  in  a  woman  of  thirty  who  died  on  die  ninth  day  of  an  attack 
of  illness  which  terminated  by  effusion  on  the  brain.  There  were  no  symp- 
toms referable  to  the  abdomen.     At  the  autops}'  the  whole  of  the  small  in- 


PLATE  LVIII. 

Ferguson's  Modification  of  Blake's  Operation  in  Suitable  Cases. 
(Author's   Case.) 


INTERNAL     AND     INFERIOR     HERNIAS  333 

testine  was  found  in  a  hernial  sac,  situated  between  the  folds  of  the  meso- 
colon. The  left  half  of  the  transverse  colon  was  found  deflected  in  a  longi- 
tudinal direction  down  to  the  middle  line  as  far  as  the  brim^  of  the  pelvis. 
The  patient  had  had  a  large  tumor  which  projected  on  each  side  of^il.  The 
jejunum  entered  the  sac  at  the  upper  and  posterior  part,  while  the  ileum 
passed  out  below,  and  on  the  right  side,  at  a  point  about  two  inches  above 
the  termination  of  that  intestine  in  the  cecum.  There  was  no  appearance  of 
an_v  constriction  having  been  exercised  on  the  intestine. 

In  a  second  case,  a  man,  aged  27,  death  resulted  from  strangulation 
of  the  intestines.  The  man  had  pain  in  the  abdomen  and  vomited  fecal 
matter.  He  died  about  forty-one  hours  after  the  onset  of  his  symptoms,. 
The  descending  colon  was  found  on  the  left  side  of  the  cecum  and  the 
small  intestines  were  contained  in  the  sac  formed  between  the  two  layers 
of  the  left  meso-colon  and  situated  on  the  left  side  of  the  descending  colon. 
The  ileum  passed  out  of  the  sac  about  two  inches  above  the  cecum,  and  at 
that  point  the  canal  of  the  intestine  was  contracted,  its  coats  thickened,  in- 
flamed, and  gangrenous. 

ILEO -COLIC  HERNIA. 

In  the  neighborhood  of  the  appendix,  cecum  and  termination  of  the 
ileum  are  fossse  which  may  be  the  seat  of  occurrence  of  a  posterior  hernia. 
Hernia  into  the  ileo-colic  fossa  is  so  rare  that  Treves  felt  himself  impelled 
to  say  that  the  ileo-colic  fossa  takes  no  part  in  the  production  of  pericecal 
hernias. 

E.  R.  Secord,of  Brantford,  Canada  (Annals  of  Surgery,  Nov.,  1906) 
reports  a  case  of  ileo-colic  hernia,  the  first  to  be  placed  on  record.  It  may 
not  be  amiss  at  this  time  to  report  the  case,  rather  fully. 

The  patient,  a  white  male,  aged  40,  complamed  of  recurring  abdominal 
pain,  obstinate  constipation,  retching  and  some  vomiting.  The  pain  was 
spasmodic  in  character,  recurrent,  and  becoming  progressively  more  severe. 
The  abdomen  was  slightl}^  distended,  especially  on  the  right  side.  There 
was  no  board-like  rigidity,  but  a  feeling  of  resistance  over  the  right  rectus 
muscle,  and  general  tenderness  over  the  whole  right  lower  quadrant.  On 
observing  the  abdomen  for  a  few  moments,  it  was  noted  that  with  the  onset 
of  the  pain  an  elevation  or  tumor,  of  about  the  size  of  an  orange,  became 
evident  below  and  to  the  right  of  the  umbilicus,  which  was  doughy,  tender, 
tympanitic,  and  localized  in  the  one  position. 

The  abdomen  was  opened  by  an  oblique  mcision  over  the  appendix 
region.  What  appeared  to  be  the  distended  and  markedly-congested  cecum 
and  colon  appeared  in  the  wound,  vv^hich,  however,  on  closer  examination 
showed  themselves  to  be  covered  by  an  additional  layer  of  peritoneum ;  the 
parietal  peritoneum  had  of  course  already  been  well  opened..  This  addi- 
tional layer  of  peritoneum  was  quite  thin,  fairly  transparent,  and  easily 
movable  over  the  subjacent  bowel.  External  to  this  mass  was  another  loop 
of  what  appeared  to  be  colon.  Following  this  latter  loop  upward  it  ap- 
peared to  be  continuous  with  the  ascending  colon,  but  on  followmg  it  down- 
ward to  the  appendix  region  no  caput  coli  or  appendix  could  be  discovered ; 


334  INTERNAL     AND     INFERIOR     HERNIAS 

and  on  searching  more  inwardly  a  taut  band  was  iound  running  in  an  oblique 
direction  downward  and  outward  from  the  root  of  the  mesentery,  roughly, 
in  a  direction  toward  the  anterior  superior  spine.  The  colon  bulging  out 
from  beneath  this  band  was  without  the  additional  layer  of  peritoneum 
noticed  above  and  on  slight  traction  being  made  on  this  loop  of  colon  it 
slipped  out  from  beneath  the  band,  followed  by  the  cecum  with  the  appendix, 
and  the  terminal  four  inches  of  the  ileum.  These  portions  of  the  bowel  were 
all  distended  and  markedly  congested,  and  in  one  area  on  the  outer  surface 
of  the  cecum  the  bowel-wall  was  ecchymotic,  and  in  the  center  of  this  a 
small  whitish  slough  was  situated.  This  slough  was  looked  for  and  found, 
since  on  withdrawing  the  bowel  from  under  the  above  mentioned  band,  a 
fecal  odor  had  immediately  become  noticeable. 

The  pouch  of  peritoneum  left  by  the  withdrawal  of  its  contained  in- 
testines was  shaped  much  like  a  rubber  tobacco-pouch,  with  its  mouth  about 
an  inch  and  a-half  across,  pointing  in  a  downward  and  inward  direction. 
When  filled  the  size  of  the  pouch  would  be  sonievvdiat  greater  than  that 
of  the  folded  fist. 

The  mouth  of  the  pouch  was  closed  by  a  single  row  of  catgut,  attach- 
ing the  taut  anterior  fold  to  the  anterior  layer  of  the  mesentery  of  the  lower 
end  of  the  ileum. 

The  patient  recovered. 

ILEO-CECAL  HERNIA. 

Aschoff  (Berliner  Klinik,  Heft  loo,  Oct.,  1896)  reports  one  case  of 
ileo-cecal  hernia  in  which  operation  was  successful.  The  patient  was  seized 
suddenly  with  pain  in  the  right  side  of  the  abdomen.  For  twenty-one  days 
symptoms  of  chronic  intestinal  obstruction  manifested  themselves,  leading 
to  a  diagnosis  of  cancer.  The  abdomen  was  opened  for  the  purpose  of 
doing  a  right  inguinal  colotomy,  when  the  ileo-cecal  hernia  of  the  small 
intestine  was  discovered.  The  hernia  was  reduced  and  the  patient  made  a 
good  recovery. 

In  1846  {London  Medical  Gazette,  page  125),  John  Snow  described  a 
case  of  this  variety  of  hernia  occurring  in  a  young  woman  who  died  on 
the  fourth  day  with  symptoms  of  acute  intestinal  obstruction.  A  sac  was 
found  at  the  site  of  the  ileo-cecal  fossa,  which  admitted  the  finger  for  about 
two  inches.     Nasse  and  Riese  have  reported  similar  cases. 

SUBCECAL  HERNIA. 

Jonnesco  collected  11  cases  of  subcecal  hernia,  7  of  which  were  stran- 
gulated, the  remaining  4  being  reduced  with  ease.  The  treatment  is  early 
abdominal   section   with   reduction   of   the   hernia. 

HERNIA  OF  PELVIC  FLOOR. 

After  two  attempts  to  correct  a  complete  hernia  of  the  pelvic  floor, 
Crile  finally  succeeded  by  performing  an  operation  which  he  describes 
{Cleveland  Medical  Journal,  July,  1906)   as  follows: 

With  the  patient  in  the  Trendelenburg  posture,  a  median  incision  of 


INTEKNAI-     AND     INFF.RIOR     HERNIAS  335 

good  length  was  made;  approximately  one-fourlh  of  the  entire  abdominal 
j^  contents  were  withdrawn  from  the  hernial  sac,  the  pelvic  floor  steadied  and 

f  the  hernia  reduced.     The  bladder  was  found  well  down  in  this  cavity  and 

totally  prolapsed.  An  anteroposterior  incision  was  made  across  the  middle 
of  the  floor  of  the  pelvis,  dividing  the  vagina  into  two  lateral  halves.  The 
vaginal  mucous  membrane  of  the  part  to  be  brought  through  the  abdominal 
incision  was  removed.  The  bladder  was  separated  from  the  vagina  for 
some  distance  downward.  It  was  then  found  that  the  vagina  and  the  floor 
of  the  pelvis  had  been  so  stretched  that  they  coUld  easily  be  brought  out 
through  the  abdominal  wound  beyond  the  surface  of  the  skin.  After  makin^ 
an  incision  through  the  abdominal  fascia  4  cm.  from  the  median  line  on 
each  side,  the  fibers  of  the  recti  were  separated  and  the  peritoneum  per- 
forated. Each  half  of  the  split  vagina  with  the  attached  uterosacral  and 
uteropelvic  ligaments  and  all  the  other  structures  of  the  floor  of  the  pelvis, 
together  with  the  round  and  broad  ligaments,  were  drawn  out  through  these 
openings  on  each  side  of  the  median  incision. 

While  the  parts  were  well  up  in  place  so  that  the  top  of  the  incised 
vagina  presented  closely  against  the  under  surface  of  the  peritoneum,  the 
latter  was  sutured  in  this  position  with  plain  catgut.' 

The  original  peritoneal  incision,  the  muscle  and  the  external  fascia 
were  then  closed,  the  latter  by  continuous  sutures  of  chromicized  gut,  after 
which  the  freed  ends  of  the  vagina  and  pelvic  floor,  which  had  been  drawn 
up  through  the  lateral  openings  in  the  peritoneum,  recti  and  fascia,  were 
united  in  the  middle  line  by  means  of  chromicized  gut.  The  skin  was  then 
dosed.  The  patient  made  a  good  recovery  from  the  operation  and  was 
discharged  in  three  and  one-half  weeks. 

For  some  time  after  the  operation  the  patient  felt  a  sensation  of 
dragging  on  the  wound  and  experienced  some  pain.  This  passed  away  after 
several  months.  She  has  been  doing  her  usual  work,  and  at  the  present 
time,  more  than  three  years  after  the  operation,  there  has  been  no  recur- 
rence of  the  hernia.  Crile  says  the  indication  for  this  operation  exists  only 
in  the  cases  of  complete  hernia  (procidentia).  ]n  the  minor  degrees  of 
prolapse  it  would  be  quite  impossible  to  carry  out  this  technic  for  want  of 
sufficient  length  of  ligaments  and  of  vagina  to  reach  to  the  external  fascia. 


CHAPTER  X. 

STRANGULATED  HERNIA. 

Strangulation  of  a  hernia  is  by  no  means  an  uncommon  occurrence, 
and  it  is  not  because  of  its  frequency  that  a  special  chapter  is  being  devoted 
to  it.  But  every  now  and  then  the  strangulation  produces  a  condition  which 
of  itself  is  of  sufficient  interest  as  well  as  importance  to  the  patient  to  war- 
rant making  special  mention  of  it. 

In  looking  over  the  literature  I  found  a  number  of  instances  which  it 
seemed  to  me  could  be  cited  with  profit  in  this  connection.  For  instance, 
Makins  (Lon.  Clin.  Soc.  Trans.,  Vol.  36)  reports  two  cases  of  strangula- 
tion which  led  to  gangrene.  One  patient,,  aged  87,  had  had.  an  irreducible 
right  inguinal  hernia  for  sixteen  years.  It  became  strangulated.  Six  inches 
of  intestine  were  very  much  inflamed,  and  there  was  one  gangrenous  spot 
with  a  small  perforation  in  its  center.  On  account  of  the  condition  of  the 
patient,  four  Lembert  stitches  were  inserted  in  such  a  manner  as  to  invert 
the  gangrenous  area.  The  bowel  was  washed.  The  patient  made  an  un- 
eventful recovery. 

The  second  patient  was  9  years  old.  He  had  a  scrotal  hernia.  There 
was  no  vomiting  and  no  constipation.  On  opennig  the  sac  a  foul-smelling, 
bloody  fluid  escaped..  The  bowel  and  omentum  were  found  in  the  sac.  The 
strangulated  area,  about  three-fourths  of  an  inch  in  diameter,  was  found 
to  be  gangrenous.  This  patch  was  invaginated  by  means  of  four  Lembert 
stitches,  and  complete  recovery  followed.  . 

A  case  of  partial  enterocele  reported  by  C.  T.  Dent  (Trans.  Lon.  Clin. 
Soc,  Vol.  15,  1881)  is  unique,  because  the  patient  was  a  male.  The  symp- 
toms corresponded  with  those  described  by  Littre.  The  sac  on  being  ex- 
posed was  thick  and  inflamed,  with  a  very  slight  stricture  at  its  neck,  which 
was  divided.  With  very  slight  pressure  the  hernia  was  reduced.  A  few 
days  after  the  operation  persistent  diarrhea  sei  in  and  the  patient  died  on 
the  sixth  day.  The  intestine,  seven  feet  below  the  pylorus,  showed  a  dark, 
semi-gangrenous  ring,  which  had  evidently  corresponded  to  the  neck  of 
the  sac  and  had  been  constricted  by  it.  A  portion  of  the  intestinal  wall 
only,  corresponding  to  the  centrally  more  healthy  part  included  in  the  ring, 
had  formed  the  hernia.  A  diverticulum  sprang  from  the  intestinal  wall, 
remote  from  the  attachment  of  the  mesentery.  Some  four  feet  below  this 
point  there  was  evidence  of  an  intense  enteritis  over  a  considerable  extent 
and  wholly  unconnected  with  the  hernia. 

J.  Hutchinson,  Jr.,  (Lon.  Clin.  Soc.  Trans.,  A'ol.  33)  reports  two  suc- 
cessful cases  of  primary  resection  of  a  gangrenous  small  intestine  during 
a  herniotomy.  The  first  patient,  a  woman,  aged  40,  had  for  two  years  had  a 
hernia  of  about  the  size  of  a  hen's  egg,  situated  m  the  left  groin,  just  below 


PLATE  LTX. 
i'erguson's  Modification  of  Blake's  Operation  in  Suitable  Cases. 
(Author's   Case.) 


STRANGULATED     HERMIA  339 

Poupart's  ligament,  and  external  to  the  spine  of  ti^e  pubes.  The  tumor  was 
irreducible.  On  opening  the  sac  it  was  found  to  contain  6  or  8  drams  of 
a  reddish  serum  and  a  knuckle  of  small  intestine.  Owing  to  the  condition 
of  the  bowel,  the  abdomen  was  opened,  and  five  mches  of  gut  were  excised. 
The  ends  were  united  by  a  double  row  of  sutures.  The  patient  miade  an 
uneventful  recovery.  After  six  years  there  was  a  return  of  the  femoral 
hernia,  but  it  was  controlled  easily  by  a  combination  of  plate  and  truss. 

The  second  patient,  a  man,  aged  29,  had  a  strangulated  right  inguinal 
hernia.  The  intestine  was  black  and  in  a  state  of  beginning  gangrene  for 
about  eight  inches  of  its  length.  Ten  inches  of  bowel  were  resected  bv 
Maunsell's  method.  Three  years  afterward  the  patient  suffered  from  in- 
flammation of  the  colon  and  died.  The  resected  portion  of  gut  did  not 
show  the  slightest  trace  of  a  narrowing  of  its  lumen.  There  were  no  ad- 
hesions. 

McGavin  {Trans.  Lon.  Clin.  Soc,  Vol.  36)  reports  a  case  of  strangu- 
lated inguinal  hernia  in  which  reduction  en  masse  >vas  eftected  by  taxis,  but 
the  patient  died.  For  nine  years  the  man  had  a  right  inguinal  hernia,  which 
had  always  been  reducible  and  never  caused  strangulation.  The  rupture 
suddenly  came  down  and  he  was  unable  to  get  it  back.  A  physician  reduced 
it,  whereupon  he  felt  great  pain  in  the  abdomen  and  vomited  immediately. 
On  the  following  day  the  vomiting  became  stercoraceous.  For  six  days 
neither  flatus  nor  motion  was  passed.  The  patient  died  from  general  peri- 
tonitis. The  post-mortem  revealed  the  reduction  eii  masse  and  the  continua- 
tion of  the  strangulation. 

In  the  NortheTH  Lancet  of  November,  18S9,  I  reported  a  case  of 
strangulated  hernia  occurring  in  a  man  who  had  worn  a  truss  for  a  number 
of  years.  The  hernia  became  strangulated  as  the  result  of  severe  exertion. 
Efforts  to  reduce  it  by  taxis  proved  unavailing.  In  addition  to  two  or  three 
ounces  of  bloody  fluid,  the  sac  contained  a  loop  of  bowel  about  ten  or  twelve 
inches  long,  very  much  congested  and  ecchymosed,  but  not  gangrenous.  The 
patient  made  a  good  recovery.  It  is  particularly  interesting  to  note  in  this 
case  that  the  operation  was  not  done  until  twenty-four  hours  after  strangu- 
lation had  taken  place,  the  patient  meanwhile  driving  thirty  miles  over  a 
rough  country  road  seeking  relief. 

Among  twenty-five  cases  of  strangulated  hernia,  reported  by  G.  T. 
Vaughan  {Medical  News,  Dec.  24,  1904)  there  were  two  of  the  properi- 
toneal  or  interstitial  variety. 

J.  C.  Da  Costa  {Annals  of  Surgery,  Feb.,  1899)  reports  two  very  in- 
teresting cases.  In  one  instance  purulent  clots  were  found  in  the  accessory 
veins  of  the  cord.  A  microscopic  examination  of  these  clots  showed  that 
they  contained  staphylococcus  pyogenes  albus.  In  the  other  case,  that  of  a 
man  who  suffered  from  prolapse  of  the  rectal  mucous  membrane,  and  who 
also  had  a  reducible  hernia  on  the  left  side,  operation  failed  to  effect  a 
cure.  The  prolapse  was  finally  excised  and  the  mucous  membrane  sutured. 
On  the  evening  of  the  third  day  while  having  a  violent  attack  of  coughing 
he  was  seized  with  pain  in  the  abdomen  and  he  then  found  that  the  rupture 
had  com.e  down.     It  was  painful  and  irreducible.     While  attempting  its  re- 


340  STRANGULATED     HERNIA 

duction  there  was  audible  a  crackling  sound  as  though  air  was  diffused 
through  the  tissue.  The  crackling  could  be  traced  from  the  left  to  the  right 
side,  apparently  along  the.  course  of  the  colon. 

An  incision  was  made,  the  hernia  exposed  and  the  sac  opened.  The 
hernia  was  found  to  consist  of  the  large  bowel,  and  within  the  meso-colon 
was  a  collection  of  air  which  crackled  when  pressed  on.  The  ascending, 
transverse  and  descending  meso-coli  were  in  the  same  condition.  The  w^ound 
was  closed.  On  examination  of  the  rectum  there  was  found  above  the  line 
of  stitches  an  ulceration  which  had  apparently  Icllowed  the  cauterization. 
When  the  bowel  was  pressed  on  air  escaped  from  the  ulcer  in  distinct  bub- 
bles. A  tube  was  introduced  through  the  opening  and  carried  into  the 
subserosa  so  .as  to  permit  of  the  escape  of  the  emphysematous  material, 
which  occurred  in  about  five  days.     The  patient  recovered. 

The  coils  were  evacuated  by  three  separate  incisions,  and  the  incisions 
were  closed  by  Lembert  sutures.  The  sac  was  not  removed  because  of  the 
condition  of  the  patient,  but  the  peritoneal  cavity  was  shut  off  from  the 
external  wound  by  means  of  a  strong  silk  ligature,  which  was  passed  around 
the  neck  of  the  sac  in  the  subperitoneal  tissue  in  such  a  way  that  when  it 
was  drawn  taut  it  closed  the  opening  as  the  string  of  a  bag  closes  its  open- 
ing.    The  patient  recovered. 

Knaggs  (Annals  of  Surgery^  April,  1900)  reports  two  cases  of  hernia 
in  which  strangulation  was  caused  by  volvulus. 

C.  A.  Porter  (Boston  \Medical  and  Surgical  Journal,  Oct.  10,  1901) 
reported  a  case  of  strangulated  inguinal  hernia  which  had  been  converted 
into  a  properitoneal  or  interstitial  hernia  by  attempts  made  by  the  attending 
physician  to  reduce  it.  The  sac  and  a  portion  of  its  contents  w^ere  found 
between  the  parietal  pertoneum  and  the  transveisalis  fascia,  having  no  re- 
lation to  the  inguinal  canal. 

A  case  of  strangulated  hernia  complicated  oy  volvulus  is  reported  by 
Parker  (Trans.  Lond.  Clin.  Soc,  Vol.  17).  The  bowel  was  liberated  and 
pulled  down  in  making  an  artificial  anus.  The  patient  continued  to  retch 
and  vomit  after  the  operation,  and  no  fecal  matter  passed  through  the  colos- 
tomy wound,  nor  per  vias  naturales.  A  median  incision  revealed  a  volvulus 
involving  six  or  eight  inches  of  the  bowel  situated  near  the  internal  orifice 
of  the  femoral  ring.     The  patient  died. 

A  very  unusual  case  is  reported  by  Marsh  (St.  Bartholoniczv's  Hospital 
Reports,  Vol.  10,  1874).  A  boy,  aged  five  months,  had  a  strangulated  in- 
guinal hernia  and  was  operated  on,  but  died  on  the  twelfth  day  from  ery- 
sipelas of  the  scrotum  and  the  abdominal  wall.  The  strangulation  occurred 
at  the  external  abdominal  ring,  but  when  this  was  divided  the  bow"el  was 
returned  easily  without  opening  the  sac.  Everything  went  well  until  the 
erysipelas  set  in. 

Marsh  (Trans.  Lond.  Clin.  Soc.,  Vol.  30)  reports  another  case,  one 
of  left-sided  strangulated  hernia,  in  which  there  was  no  fluid  in  the  sac, 
but  the  included  coils  of  small  intestine  were  densely  distended  with  a  blood- 
stained serum,  mucus  and  a  small  amount  of  fecal  matter.  The  sac  con- 
tained about  two  feet  of  small  intestine. 


STRANGULATED     HERNIA  34I 

That  strangulation  may  occur  as  the  result  of  trauma  is  shown  by  the 
case  reported  by  T.  M.  Jones  (Central  States  Medical  Monitor,  Aug.  15, 
1906).  His  patient  had  a  strangulated  right  inguinal  hernia  which  extended 
half  way  into  the  scrotum.  It  had  existed  for  about  two  years  but  never 
caused  any  trouble.  The  patient  wore  a  truss.  While  playing  polo,  he  was 
struck  by  a  ball  in  the  right  iliac  region.  Two  w  eeks  later  he  began  to  feel 
a  dull  pain  in  the  lower  abdomen  and  on  attempting  to  reduce  the  hernia  he 
was  unable  to  do  so.  The  strangulation  was  relieved  by  operation  but  the 
condition  of  the  patient  did  not  improve.  Shock  continued  and  death  en- 
sued twelve  hours  after  the  operation.  Autopsy  showed  complete  strangu- 
lation of  the  small  intestine  in  half  a  dozen  places  in  the  ileum  and  the 
jejunum  by  bands  of  fibrous  tissue  which  closed  the  lumen  of  the  bowel  a> 
completely  as  if  it  had  been  ligated.  The  adhesions  doubtless  were  the  re- 
sult of  the  trauma  of  two  weeks  previously. 

Clogg  (British  Medical  Journal,  (October  20,  1906)  collected  53  cases 
fromi  the  literature  of  strangulation  of  the  appendix  in  a  hernial  sac.  In 
the  majority  of  these  cases  the  appendix  was  the  sole  content  of  the  sac. 
Only  three  cases  occurred  in  males.  I  agree  fuliy  with  the  statement  of 
Clogg  that  a  correct  diagnosis  rarely  is  miade  in  these  cases,  and  that  they 
are  usually  taken  to  be  cases  of  ordinary  strangulated  hernia.  As  a  rule, 
these  hernias  are  of  small  size,  and  are  easily  reducible  when  the  attempt  at 
reduction  is  made  early.  Only  rarely  does  the  entire  appendix  lie  in  the 
hernial  sac,  the  apex  being  usually  the  miost  advanced  point.  Adhesions  are 
not  common. 

A  case  of  displaced  strangulated  femoral  hernia  is  reported  by  Bryant 
(Trans.  Lond.  Clin.  Soc,  Vol.  35).  The  sac  with  its  contents  was  displaced 
downward  and  inward,  through  an  opening  at  the  lower  end  of  the  femoral 
sheath,  and  in  front  of  the  adductor  muscles  on  tne  inner  side  of  Scarpa's 
triangle.  The  tumor  was  tender  on  pressure  and  the  patient  manifested 
symptoms  of  obstruction  of  the  bowel.  Although  the  patient  was  moribund, 
an  operation  was  done,  but  proved  fatal.  It  was  found  that  the  hernia  was 
displaced  into  the  fatty  connective  tissue  of  the  nmer  side  of  the  thigh,  the 
seat  of  strangulation  being  an  inch  and  a  half  below  the  femoral  ring. 

I.  J.  Buchanan  (Medical  Record,  October  8.  1904)  reports  a  case  of 
umbilical  hernia  in  which  strangulation  occurred  that  is  interesting,  not 
because  of  this  fact,  but  because  of  the  sequence  of  events  and  the  final 
outcome  of  the  case.  The  patient,  female,  aged  48,  had  had  a  large  umbili- 
cal hernia  for  about  seven  years.  For  about  one  }"ear  it  had  been  irreducible, 
and  then  suddenly  became  strangulated.  In  opening  the  hernial  sac  a  small 
incision  was  made  into  the  gangrenous  bowel,  and  most  of  its  contents  were 
removed  by  exoression.  The  cpening  was  viicn  temporal"! ly  cio-cd  vvitli  a 
ligature.  The  entire  mass  of  intestine  which  ^vas  so  large  as  to  simulate 
the  bulk  of  the  gastro-intestinal  tract,  was  in  a  state  of  complete  gangrene. 
The  hernial  ring  was  divided,  traction  was  made  on  the  gangrenous  con- 
tents in  an  efifort  to  deliver  the  adjoining  portions  of  bowel,  but  without 
avail.     The  peritoneal  cavity  was  protected  by  a  large  quantity  of  iodoform 


342  STRANGULATED     HERNIA 

gauze  packed  around  the  base  of  the  mass.  The  surface  was  covered  with  a 
gauze  dressing.     The  patient  improved  at  once. 

At  the  end  of  a  week  the  gangrenous  mass,  though  collapsed,  was  still 
attached.  A  few  days  later  the  bulk  of  the  mass  was  cut  away.  Examina- 
tion showed  that  the  mesenteric  portion  of  a  part  of  the  bowel  remained, 
due  to  the  fact  that  the  meso-cecum  and  the  meso-colon  of  the  splenic  flexure 
were  too  short  to  permit  the  passage  of  the  entire  cecum  and  splenic  flexure 
through  the  ring,  and  that  the  line  of  mortification  had  passed  through  the 
wall  of  these  parts  of  the  bowel  longitudinally,  leaving  the  distal  part  alive, 
and  its  mucous  membrane  forming  the  surface  of  the  mass  protruding  from 
the  ring.  The  destroyed  intestine  was  the  free  surface  of  the  cecum,  the 
ascending  and  transverse  colon,  with  the  distal  border  of  the  splenic  flexure. 
At  a  subsequent  operation  the  ileum  was  implanted  intp  the  sigmoid  bv 
simple  continuous  suture.     The  patient  made  a  normal  recovery. 

P.  Leech  {Lancet,  June  6,  1903)  reports  a  case  of  strangulated  left 
duodenal  hernia  in  which  the  symptoms  of  strangulation  developed  slowly. 
No  cause  could  be  found  for  the  obstruction.  Other  treatment  failing  to 
give  relief,  a  laparotom}'  was  done.  When  the  abdomen  was  opened  the 
small  intestine  was  seen  to  be  under  the  mesentery  and  a  diagnosis  of  re- 
troperitoneal hernia  was  made.  The  sac  looked  obliquely  upward  and  to 
the  right.  The  anterior  lower  margin  was  thickened  and  rigid.  The  finger 
could  be  passed  into  the  sac  and  about  a  foot  of  intestine  was  withdrawn. 
The  abdomen  was  closed  and  the  patient  made  a  good  recovery. 

A  case  of  strangulated  obturator  hernia  is  reported  by  J.  Mason  {St. 
Bartholomezv's  Hospital  Reports,  Vol.  27,  1891).  The  patient  did  not  come 
to  his  notice  until  some  months  after  the  strangulation  had  occurred.  For 
fifteen  years  she  had  noticed  two  swellings  in  the  right  groin  which  occa- 
sionally became  very  painful,  and  at  these  times  she  suffered  considerably 
from  vomiting  and  general  indisposition.  The  symptoms  usually  began  with 
bearing-down  pains  in  the  groin  and  dowm  the  thigh.  On  some  occasions 
relief  was  obtained  by  enemata,  on  others  without  any  treatment  but  rest. 
Suddenly  s}Tnptoms  of  acute  obstruction  supervened.  Under  symptomatic 
treatment,  such  as  the  use  of  enemata  and  gentle  taxis,  followed  by  the 
application  of  a  properly  constructed  truss,  the  patient  made  a  complete 
recovery.  Reduction  was  best  effected  with  the  limb  very  slightly  flexed 
and  everted,  the  outer  side  of  the  knee  still  resting  lightly  on  the  bed. 


CHAPTER  XI. 

HERNIA  IN  INFANTS. 

Quite  a  number  of  instances  are  recorded  in  the  literature  of  operation 
ior  hernia  done  on  very  young  infants.  Audion  (Presse  Medicale,  Dec. 
30,  1889)  reports  a  successful  operation  for  umbilical  hernia  done  on  an 
infant  one  hour  after  birth.  The  hernia  was  reduced  and  three  layers  of 
sutures  were  inserted.  Stolypinski  also  reports  such  a  case.  Benedict  oper- 
ated on  an  infant  three  hours  old,  and  Hinkson  operated  ten  hours  after 
birth.  Barton  did  a  radical  operation,  which  was  successful,  on  an  infant 
thirt3'--three  hours  old.  All  of  these  operations  were  done  for  umbilical 
hernias.  C.  MacLaurin  (Lancet,  May  5,  1900)  reports  a  successful  opera- 
tion for  strangulated  hernia  on  an  infant,  fourteen  days  old,  and  E.  D.  Fen- 
ner  {New  Orleans  Medical  and  Surgical  Journal,  September,  1899)  and  D. 
Power  {Lancet,  Sept.  30,  1899)  each  report  a  case  c  f  successful  operation 
for  strangulated  inguinal  hernia  done  on  patients  five  months  and  three 
months  of  age  respectively.  J.  O'Connor  {Lancet,  August  26,  1899)  re- 
ports 150  cases  of  radical  cure  of  acquired  oblique  inguinal  hernia  in  in- 
fants, with  one  death  and  two  recurrences.  Fraenkel  {Centralbl.  f.  Chir., 
No.  47,  1900)  cites  the  histories  of  68  children,  16  of  whom  were  nurslings, 
operated  on  to  effect  a  radical  cure  of  inguinal  hernia.  In  order  to  prevenr 
inflammation  of  the  wound,  he  wraps  the  lower  part  of  the  body  in  a  fixed 
bandage,  and  covers  the  wound  with  impermeable  dressings  until  it  has 
healed. 

J.  E.  Briscoe  {Lancet,  Sept.  10,  1898)  reports  a  successful  operation 
for  strangulated  hernia  done  on  an  infant  twenty-one  days  old.  It  is  inter- 
esting to  note  in  this  case  that  the  bowel  was  invested  tightly  by  the  peri- 
toneal tube  throughout  the  entire  inguinal  canal.  The  sac  appeared  to 
tenninate  abruptly  at  the  inner  ring,  thus  causing  the  physical  signs  to  re- 
semble those  of  an  inflamed  hydrocele. 

Lilienthal  {Medical  Record,  March  2,  1901)  reports  a  case  of  strangu- 
lated inguinal  hernia  occurring  in  an  infant  eight  days  old.  The  contents 
of  the  sac  consisted  of  sigmoid,  ascending  colon  and  appendix,  together 
with  a  large  part  of  the  small  intestine.  The  child  was  operated  on  success- 
fully. 

Kellock  {Lancet,  July  5,  1902)  records  a  case  of  bilateral  strangulated 
hernia  occurring  in  an  infant  ten  weeks  of  age.  He  operated,  but  two  days 
later  there  developed  an  inguinal  hernia  on  the  opposite  side.  It  was  re- 
duced easily.  Fifteen  days  later,  however,  it  became  strangulated  and  an 
operation  had  to  be  done. 

Reid  {Nezv  York  State  Journal  of  Medicine,  1903)  operated  success- 
fully on  a  case  of  strangulated  hernia  in  an  infant  twenty-seven  days  old. 


344-  HERNIA    IX    INFANTS 

W.  B.  Coley  has  operated  on  ii  patients  under  two  years  of  age,  with 
only  one  death.     Six  were  under  one  year  of  age. 

Corner  {Lancet,  Aug.  20,  1904)  beHeves  in  the  curabihty  of  hernia  in 
young  children  by  means  of  a  truss,  except  in  cases  of  large,  uncontrollable 
hernias,  in  irreducible  or  difficultly  reducible  or  incarcerated  hernias,  and 
in  strangulated  hernias,  when  there  is  a  congenital  sac.  Corner  is  not  alone 
in  this  belief,  which  is  held  by  many  operators  of  large  experience. 

H.  J-  Stiles  {British  Medical  Journal,  Oct.  i,  1904)  records  360  con- 
secutive operations,  26  per  cent,  of  which  were  done  on  infants  under  one 
year  of  age.  Unlike  Corner,  Stiles  does  not  believe  in  mechanical  treat- 
ment. He  says  that  in  cases  in  which  the  hernia  was  supposed  to  have 
been  cured  by  wearing  a  truss  during  childhood,  strangulation  is  likely  to 
occur  in  adult  life  as  the  result  of  a  strain.  Stiles  had  five  deaths  in  his 
series.  In  24  of  his  cases  the  cecum  was  found  in  the  sac,  and  in  5  of  the 
36  cases  of  inguinal  hernia  occurring  in  girls,  the  sac  contained  the  ovarv 
and  tube. 

The  operation  employed  by  Stiles  was  practically  the  one  devised  by 
Banks,  isolation  and  ligation  of  the  sac  at  the  neck  on  a  level  with  the  in- 
ternal ring  without  splitting  the  aponeurosis  of  the  external  oblique  muscle. 
To  close  the  canal  he  says  all  that  is  necessary  in  the  majority  of  the  cases 
is  to  introduce  a  single  catgut  suture  through  the  outer  pillar  of  the  ring 
close  to  Poupart's  ligament  across  the  canal,  superficial  to  the  cord,  and  then 
introducing  it  from  within  outward  through  the  conjoined  tendon  and  the 
inner  pillar  of  the  ring. 

Schenk  {Prager  Med.  Woch.,  No.  i,  1900)  reports  a  case  of  congenital 
lateral  ventral  hernia  occurring  in  an  infant.  The  hernia  was  about  the 
size  of  a  walnut,  and  was  situated  on  the  right  side  betw^een  the  ribs  and 
iliac  crest.  The  abdominal  wall  at  this  point  was  weak,  and  the  knee,  when 
strongly  flexed  on  the  abdomen,  fitted  into  the  gap  in  the  muscles. 


CHAPTER  XII. 

UNUSUAL  FORMS  OF  HERNIA. 

Many  unusual  forms  of  hernia  have  been  recorded  in  the  literature 
by  various  observers.  As  a  rule  the  diagnosis  was  not  made  until  at  the 
time  of  cutting  down  on  the  tumor.  A  number  of  these  instances  have 
been  mentioned  already  in  the  first  chapter  of  Part  I,  in  connection  with 
the  contents  of  the  hernial  sac,  and  I  will  now  cite  from  the  literature  a 
few  cases  that  are  of  more  than  passing  interest,  not  only  because  of. the 
infrequency  of  their  occurrence,  but  also  because  they  are  quite  likely  to 
be  mistaken  for  some  condition  other  than  hernia.  The  old  saying  that 
"there  is  nothing  new  under  the  sun"  often  is  exemplified  in  surgery,  espe- 
cially in  the  dislocation  of  a  viscus. 

Greenhow  (Trans.  Lond.  Clin.  Soc,  1880)  reported  a  case  of  intes- 
tinal obstruction  caused  by  a  hernia  through  the  mesentery  of  a  Meckel's 
diverticulum,  which  had  retained  its  attachment  to  the  umbilicus.  The  pa- 
tient, male,  7  years  of  age,  presented  symptoms  that  pointed  both  to  in- 
tussusception and  to  appendicitis.  There  was  no  evidence  of  the  exist- 
ence of  a  peritonitis  until  the  day  of  death.  Intestinal  peristalsis  was  sus- 
pended, but  there  was  not  complete  obstruction.  The  ileum  was  very  much 
distended.  Attached  to  the  abdominal  wall  opposite  the  umbilicus  was  a 
fibro-fatty  cord  half  an  inch  in  length,  which  passed  on  to  the  extremity  of 
a  well-developed  Meckel's  diverticulum,  which  was  nearly  equal  in  calibre 
to  the  ileum  from  v/hich  it  sprang.  Except  for  its  attachment  at  the  umbil- 
icus, this  diverticulum  was  free  for  about  two  inches,  but  the  remaining 
one  and  one-half  inch,  together  with  several  coils  of  collapsed  ileum,  ap- 
peared to  be  included  within  the  ring-like  opening  situated  in  the  diver- 
ticular mesentery.  The  ring  was  formed  by  a  loop-like,  fibro-fatty  cord 
passing  from  the  diverticulum  above  to  the  general  mesentery  across  the 
ileum,  nine  and  a  half  inches  of  which  had  passed  through  the  ring.  Be- 
sides the  diverticulum  a  knuckle  of  bowel  had  been  forced  through  the 
ring,  thus  completing  the  strangulation. 

One  case  of  rupture  of  Douglas'  cul  de  sac,  with  protrusion  of  the 
uterine  appendages  through  the  vulvar  orifice  is  reported  as  having  oc- 
curred in  a  woman,  50  years  of  age.  I  have  also  seen  one  such  case,  which 
I  have  reported  elsewhere. 

A.  R.  Moulton  {Philadelphia  Med.  .Tour.,  March  16,  1906)  reports  a 
case  of  rupture  of  the  rectum  which  was  followed  by  hernia  of  the  small 
intestine. 

A  rare  case  of  strangulated  recto-cecal  hernia  was  reported  by  Ma- 
rion {Gas.  heb.  de.  Med.  et  Chir.,  April  11,  1901).  The  patient,  a  woman, 
had  signs  of  intestinal  obstruction,  but  on  opening  the  abdomen   the   in- 


346  UNUSUAL     FORMS     OF     HERNIA 

testine  was  found  engaged  between  the  cecum  and  the  ihac  fossa.  It  was 
freed  and  the  patient  recovered. 

An  instance  of  a  right  cecal  hernia  comphcated  by  hydrocele  and 
suppurative  appendicitis  is  reported  by  R.  C.  Turck  {Jour.  A.  M.  A.,  April 
26,  1902).  The  patient  had  had  a  right  inguinal  hernia  for  over  sixty 
years,  and  a  small  hernia  on  the  left  side  about  twenty  years.  The  ap- 
pendix, testicle,  hydrocele  and  hernial  sac  being  agglutinated  together, 
were  removed  en  masse.     The  patient  recovered. 

The  fourth  case  on  record  of  extraperitoneal  crural  cystocele  is  re- 
corded by  S.  Mercade  {Gaz.  des  Hop.,  July  3,  1902).  The  patient,  female, 
aged  53,  had  a  small  femoral  hernia  on  the  right  side.  A  diagnosis  of 
epiplocele '  was  made,  and  at  the  operation  a  slightly  pyriform  body  was 
found  next  to  the  omentum.  On  cutting  into  it  a  gush  of  urine  showed  it 
to  be  the  bladder. 

Two  very  rare  forms  of  hernia,  obturator  hernia  of  the  bladder  and 
of  the  Fallopian  tube,  were  noted  by  R.  J.  Gladstone  {Annals  of  Surgery, 
December,  1901).  On  the  right  side  a  U-shaped  loop  of  the  Fallopian  tube 
was  found  lying,  together  with  a  portion  of  the  mesosalpinx,  within  a 
small  peritoneal  sac.  On  the  left  side  a  corner  of  the  bladder  wall  an- 
terior to  the  line  of  reflection  of  the  peritoneum  was  found  firml}^  fixed 
to  the  beginning  of  the  obturator  canal. 

F.  Flaherty  {American  Medicine,  June  21,  1902)  reports  a  case  of 
traumatic  hernia  of  the  diaphragm  following  a  wound  of  the  thorax.  The 
patient  fell  on  a  hay-knife,  which  penetrated  between  the  seventh  and 
eighth  ribs,  on  the  left  side,  at  the  anterior  axillary  line  and  emerged  be- 
tween the  tenth  and  eleventh  ribs  close  to  the  spine.  He  presented  symp- 
toms of  obstruction  of  the  bowel.  Necropsy  showed  the  stomach  filled 
with  gas,  and  filling  the  left  chest  except  a  small  part  above  where  the 
collapsed  lung  was  found.  The  opening  in  the  diaphragm  was  three 
inches  in  length,  and  in  its  passage  through  it  the  stomach  carried  along 
part  of  the  great  omentum. 

C.  E.  Black  {Illinois  Medical  Journal,  Jan.,  1904)  reports  a  very  re- 
markable case  of  hernia  of  the  ovary,  appendix  and  Meckel's  diverticulum 
into  an  inguinal  sac.  The  appendix  was  gangrenous  and  had  ruptured, 
and  six  inches  of  bowel  had  to  be  resected,  together  with  the  appendix, 
cube  and  ovary. 

W.  A.  Dennis  {St.  Paid  Medical  Journal,  Oct.,  1905)  records  a  suc- 
cessful operation  for  traumatic  diaphragmatic  hernia  following  a  severe 
contusion  of  the  left  thorax  from  the  end  of  a  buggy  pole.  The  blow  was 
received  just  behind  the  eighth  chondro-cdstal  junction,  and  while  not 
penetrating  was  of  sufficient  force  to  confine  the  patient  to  bed  for  three 
months.  The  symptoms  which  led  to  the  operative  intervention  did  not 
manifest  themselves  until  eighteen  months  after  the  reception  of  the  in- 
jury. The  hernia  consisted  of  omentum,  transverse  colon  and  the  greater 
part  of  the  stomach. 

M.  Metzenbaum  {Journal  A.  M.  A.,  Oct.  28,  1905)  records  a  case  of 
umbilical  hernia  perforating  the   abdominal  wall.     The  hernia  was  never 


/ 


\      / 

7 


PLATE  LX. 

Final    Result   of    Operation    for   Umbilical    Hernia. 
(Author's   Case.) 


y 


L-^NUSUAL     FORMS     OF     HERNIA  349 

reducible.  At  the  operation  it  was  found  that  nearly  all  of  the  small  in- 
testine, together  with  cecum  and  appendix  and  a  large  portion  of  the 
omentum,  comprised  the  hernia.  Loops  of  intestine  were  grown  together 
with  masses  of  the  abdominal  fat  and  omentum,  and  in  many  places  were 
firmly  adherent  to  the  abdominal  wall  itself.  It  was  for  these  reasons  that 
the  hernia  was  never  reducible. 

Another  case  of  umbilical  hernia  containing  a  diverticulum  of  con- 
genital origin  is  reported  by  A.  J.  Landman  (Lancet,  Nov.  Ii,  1905),  as 
occurring  in  a  child  one  day  old.  The  tumor  was  of  about  the  size  of  an 
orange,  and  its  coverings  consisted  of  the  constituent  elements  of  the 
umbilical  cord.  The  sac  contained  small  intestine,  one  part  of  which 
consisted  of  a  blind  diverticulum,  and  this  was  the  part  adherent  to  the 
sac  wall. 

Although  Richter's  hernia  is  believed  to  be  of  rather  rare  occurrence, 
V.  W.  Low  {Lancet,  Jan.  28,  1905)  reports  four  cases  under  his  care 
inside  of  a  year.  The  patients  were  women  who  had  right-sided  femoral 
hernias, 

Oliver  (Annals  of  Siirgery,  May,  1901)  cites  three  cases  of  properi- 
toneal  hernia.  The  first  two  cases  belong  to  that  group  in  which  the  her- 
nia lies  in  the  subperitoneal  layer.  The  third  case  belongs  to  the  group 
in  which  the  hernia  lies  between  the  internal  and  external  oblique  muscles. 
One  of  the  cases  was  not  discovered  until  the  necropsy. 

L.  J.  Mitchell  (American  Journal  of  Medical  Sciences,  Nov.,  1903) 
describes  two  cases  of  retroperitoneal  hernia.  Both  occurred  into  the 
paraduodenal  fossa. 

C.  T.  Andrews  (Lancet,  Jan.  24,  1903)  discovered  one  case  on  the 
post-mortem  table. 

A.  E.  Halsted  (Annals  of  Surgery,  May,  1906)  reports  a  case  of 
strangulated  inguino-properitoneal  hernia  occurring  in  a  man  fifty-two 
years  old,  who  had  had  a  right  inguinal  hernia  for  six  years.  It  finally 
became  as  large  as  two  fists.  A  truss  was  worn  with  satisfaction.  During 
a  severe  strain  the  hernia  slipped  from  under  the  truss  and  attempts  at  re- 
duction failed.  Hot  applications  were  made,  and  after  an  hour  the  hernia 
was  reduced,  but  the  swelling  did  not  disappear,  as  on  former  occasions. 
The  pain  was  lessened,  but  did  not  subside  entirely.  The  large  tumor 
had  disappeared,  but  there  v.^as  present  in  the  inguinal  region  a  small  mass 
which  was  exceedingly  sensitive  to  touch.  The  inguinal  canal  was  empty. 
With  the  finger  in  the  canal,  a  tum.or  could  be  felt  above  and  to  the  inner 
side  of  the  external  abdominal  ring,  in  the  abdominal  wall.  After  expos- 
ing the  external  abdominal  ring,  a  sac  was  found  extending  from  the  ring 
down  into  the  scrotum.  The  inguinal  sac  contained  a  small  quantity  of 
bloody  serum.  On  pulling  down  on  the  inguinal  sac  the  neck  of  the  sec- 
ond sac  was  brought  into  view.  It  contained  a  small  knuckle  of  intes- 
tine and  a  piece  of  omentum,  dark  in  color  and  edematous.  It  was  freed 
from  the  skin,  drawn  out  beyond  the  point  of  constriction,  ligated  and 
cut  off.     The  stump  was  pushed  back  into  the  abdomen.     With  the   re- 


350  UNUSUAL     FORMS     OF     HFRNIA 

placement  of  the  omentum  the  knuckle  of  gut  was  freed  and  dropped 
back  into  the  abdominal  caviry. 

The  second  sac  was  found  to  occupy  a  cavity  between  the  peritoneum 
and  the  transversalis  fascia.  The  cavity  containing  it  was  above  and  to 
the  inner  side  of  the  inguinal  canal.  The  sac  opened  by  a  common  orifice 
with  the  first  sac  into  the  abdominal  cavity.  This  sac  was  not  as  large 
as  the  first.  The  common  neck  of  the  two  sacs  was  incised  beyond  the 
abdominal  orifice,  and  the  resulting  opening  in  the  peritoneum  closed  by 
suture.     Recovery  with  cure  of  the  hernia  resulted. 

The  second  case  was  one  of  left  inguino-interstitial  hernia,  occur- 
ring in  a  man,  aged  65,  who  had  had  a  large  inguinal  hernia  for  about 
thirty  years.  A  truss  retained  the  hernia  for  part  of  this  time.  At  the 
operation  the  hernial  sac  was  found  to  extend  from  the  external  ring  down 
into  the  scrotum.  It  was  empty.  The  aponeurosis  of  the  external  oblique 
was  incised  from  the  external  to  the  internal  ring,  exposmg  the  neck  of 
the  second  sac.  This  sac  was  about  three  and  a  half  inches  long,  and  com- 
municated with  the  first  or  inguinal  sac.  Both  sacs  opened  mto  the  abdom- 
inal cavity  by  a  common  orifice,  which  admitted  two  fingers.  The  second 
sac  lay  beneath  the  aponeurosis  of  the  external  oblique,  resting  on  the 
internal  oblique.  It  contained  a  loop  of  intestine  about  six  inches  in 
length,  which  was  not  adherent  and  which  was  readily  replaced  into  the 
abdomen.  A  purse-string  suture  was  passed  around  the  common  neck 
of  the  two  sacs,  and  these  were  removed.  The  abdominal  cavity  was 
closed  by  tightening  the  purse-string  suture.     The  hernia  was  cured. 

Other  instances  of  interstitial  hernia  have  been  reported  by  Auvray, 
Mueller,  Fredet,  Bruno,  and  others. 

F.  T.  Stewart  {Phila.  Med.  Joiir.,  Feb.  9,  1901)  reports  a  case  of 
enormous  ventral  hernia  occurring  in  a  woman  40  years  of  age.  The  con- 
tents of  the  sac  consisted  of  the  lower  half  of  the  stomach,  of  all  the  trans- 
verse colon,  the. omentum  and  most  of  the  small  intestine.  The  sac  was 
emptied  under  great  difficulty,  but  the  patient  made  a  speedy  recovery. 

English  {Trans.  Lon.  Clin.  Soc,  Vol.  17,  p.  270)  reports  a  case  of  a 
man,  aged  62,  who  presented  himself  for  the  relief  of  a  very  large  abdom- 
inal hernia  at  the  right  semi-lunar  line.  It  measured  16  inches  in  the 
vertical  diameter  and  13  inches  in  the  transverse.  It  had  existed  twelve 
years. 

In  my  own  practice  I  had  a  case  of  hernia  following  vasectomy  in  a 
patient  twenty-two  years  of  age,  from  whom  I  removed  the  right  epididy- 
mis, vas  deferens,  and  seminal  vesicles.  On  account  of  the  persistent  hem- 
orrhage the  cavity  was  packed  very  firmly  from  the  internal  abdominal 
ring  down  to  the  base  of  the  bladder.  The  packing  was  removed  at  the 
end  of  a  week  and  renewed.  Within  six  months  the  patient  returned  with 
a  hernia  of  that  region.  I  operated  after  my  method,  and  the  man  Ijas  re- 
mained cured  for  more  than  four  years. 

Two  years  ago  I  saw  in  consultation  with  Dr.  Albert  Peacock,  of 
Chicago,  a  woman  who  was  pregnant  about  three  months.  She  com- 
plained of  a  vague  pain  in  the  pelvis,  which  I  found  was  due  to  a  knuckle 


PLATE  LXI. 
Hernia  Into  Ileo-colic  Fossa.     (Secord's  Case.) 
A.  Hernial  sac.     B,  Mouth  of  sac. 


UNUSUAL     FORMS     OF     HERNIA  ^C\ 

of  bowel  descending  behind  the  cervix  through  Douglas'  pouch.  It  was 
covered  on  the  vaginal  side  by  a  very  thin  membrane.  It  was  deemed 
advisable  to  treat  the  patient  on  the  expectant  plan;  therefore  tampons 
of  gauze  were  inserted  so  as  to  keep  the  bowel  reduced  until  after  parturi- 
tion. The  patient  went  on  to  the  termination  of  her  pregnancy  without 
any  further  trouble.  The  hernia  has  not  been  noticed  since,  and  the 
woman  has  not  applied  for  any  relief. 

I  have  had  two  cases  of  right  oblique  inguinal  hernia  following  a 
direct  trauma.  One  of  the  patients,  a  voung  man,  28  years  of  age,  was 
pitching  sheaves  when  his  hand  slipped  and  the  end  of  the  pitchfork 
struck  him  in  the  right  inguinal  region,  tearing  the  internal  oblique  muscle 
from  its  attachment  to  Poupart's  ligament.  The  pain  was  so  intense  that 
the  young  man  went  to  bed.  On  examination  I  felt  a  distinct  deficiency  in 
the  inguinal  region,  and  at  the  time  of  the  operation,  which  was  done  im- 
mediately, I  found  that  the  internal  oblique  muscle  had  been  torn  away 
from  Poupart's  ligament,  and  that  the  internal  ring  had  been  enlarged  to 
the  size  of  the  end  of  the  pitchfork  handle.  I  restored  the  parts  to  their 
normal  position  by  suturing  the  redundant  transversalis  fascia  over  the 
slackened  peritoneum,  without  opening  the  peritoneal  cavity,  and  the  in- 
ternal oblique  muscle  to  Poupart's  ligament,  closing  the  wound  in  the 
usual  manner.     The  patient  made  a  perfect  recovery. 

The  other  patient  was  walking  around  the  barn  in  the  dark  and  fell 
down,  his  inguinal  region  striking  the  sharp  corner  of  a  board.  He  re- 
mained in  bed  for  about  a  week,  when  he  felt  sufficiently  recovered  to  re- 
turn to  his  work.  Three  months  afterward  he  applied  to  me  for  rehef  from 
a  hernia  into  the  scrotum  which  he  could  not  retain  with  a  truss.  I 
operated  and  found  that  the  internal  oblique  muscle  had  bee'h  torn  from 
Poupart's  ligament  almost  up  to  the  anterior  superior  spine.  The  internal 
abdominal  ring  was  very  much  enlarged.  The  typic  operation  was  done 
and  a  cure  was  effected. 

Another  case  of  traumatic  hernia  through  the  left  rectus  muscle 
occurred  in  a  very  strong  man  who  was  doing  some  work  on  the  highway 
with  a  scraper.  The  implement  inflicted  a  very  severe  wound  opposite 
the  umbilicus  at  about  the  center  of  the  left  rectus  abdominis  muscle,  the 
force  of  the  impact  being  sufficient  to  lift  him  bodilv  and  throw  him  at 
the  horse's  feet.  Although  he  complained  of  some  tenderness  in  that  re- 
gion, the  hernia  did  not  develop  sufficiently  to  be  diagnosticated  until  six 
years  afterward.  At  that  time  I  opened  his  abdomen  and  found  a  hernial 
protrusion  of  the  bowel  through  the  left  rectus  muscle,  at  the  site  of  the 
original  injury.    A  cure  was  affected  by  laparotomy. 

Another  very  curious  case  was  that  of  a  man  who  acquired  an  epi- 
gastric hernia  as  the  result  of  carrying  a  flag,  the  end  of  the  staff  resting 
on  his  abdomen  belov^^  the  ensiform.  cartilage. 

Another  man  developed  an  epigastric  hernia  from  the  use  of  a  spoke- 
shave,  which  he  had  employed  for  making  shingles  and  ax  handles  for 
about  twelve  years.  He  attributed  the  injury  to  the  fact  that  while  making 
an  ax  handle  the  end  of  it  was  placed  against  the  abdomen  just  above  the 


x 


354  UNUSl'AL     FORMS     OF     HERXIA 

umbilicus,  and  the  spoke-shave  was  drawn  toward  him.  Both  these  cases 
were  operated  with  satisfactory  results. 

I  had  one  patient  who  suffered  from  six  hernias  (Fig.  i),  two  epi- 
gastric, one  direct  and  one  indirect  inguinal  hernia,  one  femoral,  and  one 
interstitial,  subcutaneous  hernia.  The  banner  case  is  that  of  a  woman 
who  presented  ten  very  distinct  hernias,  two  femoral,  two  oblique  inguinal, 
a  large  ventral  hernia  through  the  scar  of  an  old  hysterectomy  wound, 
one  ventral  hernia  following  a  nephrectomy,  three  forms  of  umbilical 
hernia  external  and  visible,  and  one  interstitial  umbilical  hernia  extending 
between  the  transversalis  fascia  and  the  rectus  muscle.  This  last-named 
hernia  became  partially  strangulated,  and  gave  the  indication  for  the  oper- 
ation. I  operated  on  all  these  hernias  at  one  sitting,  and  the  patient  made 
an  uneventful  recovery. 

The  umbilical  hernia  had  been  operated  on  by  the  late  John  B.  Hamil- 
ton some  years  previously,  and  when  it  returned,  and  several  of  the  other 
hernia^-  had  developed,  the  woman  went  to  him  for  advice.  He  refused 
to  operate  because  she  was  syphilitic. 

The  hernias,  wdth  one  exception,  were  comparatively  small.  The  oper- 
ation was  done  inside  of  two  hours,  and  for  two  years  at  least  she  remained 
cured.     Since  then  I  have  lost  track  of  her. 

Some  time  ago  I  saw  a  man  who  had  been  operated  elsewhere  for 
a  double  oblique  inguinal  hernia  by  the  Bassini  method.  Both  hernias  re- 
curred and  there  also  developed  two  direct  inguinal  hernias.  I  performed 
the  typic  operation  for  the  oblique  inguinal  hernias,  and  the  lower  angle 
of  the  wound  was  protected  after  the  method  of  Bloodgood,  transplanting 
the  right  rectus  muscle. 

I  encountered  a  very  unusual  form  of  vesico-rectal  hernia  in  a  man, 
27  years  of  age,  who,  while  working  in  the  field,  allowed  his  bladder  to 
become  over-distended.  He  fell  from  a  sheaf  of  wheat,  striking  the  pubic 
region  very  severely.  He  had  a  verj-  severe  pain  in  the  pelvis,  and  although 
he  felt  the  desire  to  urinate,  he  was  unable  to  do  so.  I  saw  him  twenty- 
four  hours  afterward,  and  immediately  catheterized,  but  failed  to  get  any 
urine.  I  examined  him  per  rectum,  and  found  a  large  mass  protruding 
into  the  bowel  and  filling  the  true  pelvis.  Suspecting  this  mass  to  be  the 
bladder,  I  passed  a  silver  catheter  and  removed  more  than  a  quart  of 
urine.  As  the  urine  w^as  being  withdrawn,  the  tumor  in  the  pelvis  gradu- 
ally diminished  in  size,  until  it  completely  disappeared. 

With  two  fingers  in  the  rectum,  I  pressed  the  sac  back  into  the  blad- 
der and  then  inserted  a  self -retention  catheter,  asking  the  patient  to  leave 
it  in  place  for  three  days,  which  he  did.  I  saw  him  again  on  the  fourth 
day,  and  found  that  he  was  able  to  retain  and  void  his  urine  at  will. 

Eight  years  ago,  at  the  request  of  Dr.  Donald  3.1acrea,  Sr.,  of  Council 
Bluffs,  Iowa,  I  operated  on  a  child,  one  week  old,  for  a  funicular  hernia  of 
the  small  intestine.  The  distended  cord,  which  formed  the  sac,  became 
gangrenous  and  ulcerated.  The  coils  of  intestine  were  agglutinated.  I  re- 
moved the  entire  umbilicus,  released  the  agglutinated  intestines,  and  re- 
turned them  into  the  abdominal  cavity.    After  flushing  the  peritoneal  cavity 


PLATE  LXII. 

A.  Loop  of  jejunum  into  lesser  cavity  of  omentum.     B.   Great  omentum. 

C.   Transverse  colon. 
(Author's   Case.) 


UNUSUAL     FORMS     OF     PIERXIA 


357 


with  normal  salt  solution,  the  wound  in  the  abdominal  %vall  was  closed 
with  interrupted  stitches  of  silkworm  gut.  Unfortunately,  the  child  died 
of  exhaustion  about  five  days  afterward.  There  was  no  evidence  of  peri- 
tonitis or  of  infection  elsewhere. 


CHAPTER  XIII. 

LOCAL  ANESTHESIA  IN  HERNIA  OPERATIONS. 

Although  I  do  not  approve  of  the  use  of  local  anesthesia  in  opera- 
tions for  the  cure  of  hernia,  it  is  of  more  than  passing  interest  to  review 
in  this  connection  the  work  that  has  been  done  by  J.  A.  Bodine  (Medical 
Record,  October  21,  1905).  Bodine  has  operated  on  284  patients,  with 
300  hernias,  under  local  anesthesia,  without  a  death  or  suppurating  wound. 
By  means  of  Schleich's  infiltration  method  the  amount  of  cocain  is  re- 
duced to  a  minimum  and  limited  to  a  small  area,  producing  acute  local 
anemia,  effectually  retaining  the  fluid  in  one  spot.  Cocainization  of  a  sen- 
sory nerve  trunk,  abolishing  pain  sensation  in  the  region  supplied  by  it, 
renders  it  possible  to  operate  for  hernia  by  its  use.  The  operative  area 
is  superficial,  and  the  region  restricted  by  the  anatomy  of  the  parts.  In 
strangulated  hernia,  local  anesthesia  does  not  increase  the  shock,  while 
general  anesthesia  is  often  too  great  a  load  to  be  borne.  The  local  anes- 
thetic permits  of  the  application  of  hot  towels  to  a  possibly  gangrenous 
intestine  for  some  time,  in  order  to  determine  whether  it  will  react.  The 
operation  does  not  give  rise  to  the  danger  of  injury  to  the  nerve  fibers.  The 
danger  to  a  line  of  deep  sutures  from  vomiting  is  done  away  with.  There 
is  no  danger  of  cocain  poisoning  with  the  small  dose  necessary — that  is, 
one-half  grain  injected  intermittently  throughout  an  hou-r.  Morphin 
given  after  the  operation  would  act  as  an  antidote  were  poisoning  possible. 
The  operation  is  more  thorough  because  of  the  absence  of  haste  and  the 
lack  of  need  to  save  the  patient  pain.  There  are  no  evidences  of  pain 
during  the  operation.  The  cocain  solution  should  be  made  fresh.  The 
solution  is  0.2  per  cent,  for  infiltration  of  the  skin  and  nerve  trunks,  and 
for  subdermic  infiltration  half  this  strength  is  used.  The  line  of  skin 
incision  should  be  infiltrated  throughout  its  extent  sufficiently  tightly  to 
maintain  the  local  anesthesia  for  an  hour.  The  aponeurosis  of  the  external 
oblique  requires  no  infiltration.  It  should  be  incised  over  the  situa- 
tion of  the  underlying  ring ;  the  ilioinguinal  nerve  will  be  exposed  by  re- 
tracting the  flaps,  and  its  trunk  is  then  cocainized  by  a  few  drops  of  the 
solution.  The  incision  may  be  carried  painlessly  into  the  external  ring, 
and  the  flaps  reflected  to  expose  Poupart's  ligament  and  the  conjoined  ten- 
don. The  iliohypogastric,  if  found,  may  be  cocainized.  The  margins  of 
the  internal  ring  are  infiltrated.  A  line  of  infiltration  along  the  long  axis 
of  hernial  protrusion  permits  a  clear  cut  through  the  hernial  sac  and  cov- 
erings. The  neck  of  the  sac  is  infiltrated,  dissected  away  from  the  under- 
lying cord,  ligated,  and  amputated.  The  genitocrural  nerve  is  cocainized. 
The  sac  is  dissected  awav  from  the  cord,  and  the  operation  is  completed. 


LOCAL    ANESTHESLV     IN     HERNL\     OPEK-VTIONS  35Q 

Operation  on  the  female  is  easier  than  on  the  male,  because  the  round  hga-' 
ment  is  less  sensitive  than  the  cord. 

J.  H.  Bloodgood  has  also  made  use  of  local  anesthesia  in  hernia  opera- 
tions. He  believes  that  it  is  especially  indicated  in  cases  of  strangulated 
hernia,  and  in  cases  where  the  hernia  is  very  large. 

From  1897  to  1899,  a  period  of  two  years,  49  herniotomies  were  per- 
formed at  the  Johns  Hopkins  Hospital  under  cocaine  anesthesia.  In  the 
majority  of  these  cases  the  administration  of  a  general  anesthetic  v/as  either 
deemed  unnecessary  or  it  was  contraindicated. 

In  1902  Frank  Martin  reported  4  herniotomies  done  under  subarachnoid 
anesthesia.  One  of  the  patients  was  68  years  of  age,  a  confirmed  alcoholic, 
with  marked  cardio-vascular  changes,  chronic  bronchitis,  and  nephritis.  No 
ili-efTects  followed  the  operation. 

Alexander  Lyle  did  fifteen  herniotomies  under  cocaine  anesthesia,  with 
most  excellent  results. 


INDEX. 


Page. 

Abdominal   cavit\',    exploration    of    . .  .  69 

wall,  repair  of  large  defects  in   . .  .  315 

wall,  weak  points  of   9 

Abscess    of    scrotum    197 

prevention  of  stitch-hole   143 

Actinomj'cosis,  following  herniotomy  .  193 

Adhesions,  separation  of  43 

Age,  influence  of  on  herniotom}- 33 

Alcohol  as  an  antiseptic   no 

Alcoholism   and   herniotomy    34 

Andrews'  imbrication  operation  for  in- 
guinal hernia   267 

Anesthesia,    local,    in    herniotomy    ....  358 

Antiseptics 109 

Appendectomy  after   herniotomy    172 

Appendix,  in  hernial  sac 19,  20,  21,  22 

retention  cyst  of  in  sac   21 

•     strangulation   of   in   hernial   sac    .  .  341 

Arms,  disinfection  of   119 

Auto-intoxication   89 

B 

Bacilli,  varieties  of    85 

Bacteria,  biologic  division  of   85 

classification  of   84 

pyogenic 86 

where  found  in  body   90 

Bacteriology,  surgical   83 

Baldwin's  operation  for  femoral  hernia290 
Ball's  operation  for  femoral  hernia...  289 
operation  for  inguinal  hernia  ....  250 
Banks'  operation  for  femoral  hernia  .  .  289 
Barker's  operation  for  femoral  hernia.  289 
Barnhill's  operation  for  inguinal  hernia  263 

Bartlett's  filigree   315,  316 

Bassini's  operation  for  femoral  hernia  290 

operation  for  inguinal  hernia 229 

operation,   results  from    

202,  293,  204,  207,  208 

Beck's  operation  for  inguinal  hernia  .  .  242 
Benjamin's  operation  for  inguinal  her- 
nia     246 

Bic3^cling  in  hernia    279 

Bishop's  operation   for  inguinal  hernia  259 
Bladder,  diseases  of  following  herniot- 
omy        167 

diverticulum  of  in  sac 19 

hernia  of  into  rectum    66 

hernia  of  through  pelvic  outlet  ....      19 

injury  of  during  herniotomy 168 

in  sac   19 


Blake's  operation   for  umbilical  hernia  307 

Bloodgood's  method,  results   from   .  . .  203 

Blood  pressure,"  observations  on  150 

Boeckel's  operation  for  umbilical  hernia  308 

Boric    acid    :  115 

saturated  solutions  of  54 

Bowel,  perforation   of    198 

resection  of    198 

Bronchitis,  post-operative    191 

Butler's   operation   for  inguinal   hernia  258 

C 

Canal  of  Nuck,  hydrocele  of  198 

Carbolic  acid  109 

acid    solutions,    preparation   of.  .53,    54 

Castration,  following  herniotomy 168 

Catgut,  Abbott's  chromic   127 

Abbott's  chromic  iodized 127 

Abbott's  iodized   127 

as  a  source  of  infection   94 

Bartlett's   128 

cumolized    127 

Esmarch's   124 

Ferguson's    129 

formalin 129 

formalin  chromic    129 

iodized   128 

Lockwood's 124 

Ochsner's 128 

preparation    of    45,    46 

sterilization  of   123,   124,   127,   128 

von  Bergmann's 124 

Cecum,  hernia  of   19,  2.2 

Cellulitis  of  round  ligament 198 

Champonniere's  operation  for  umbilical 

hernia  - 313 

Chicago       Hospital      operating      room 

technic   52 

Chlorine    116 

Chloroform  poisoning,   resuscitation  in  150 
Colej^'s  operation  for  femoral  hernia.  .   300 

Colostomy,  results  from   213 

Condamin's     operation     for     umbilical 

hernia  313 

Constitutional  diseases  and  herniotomx-     t,j 
Cooper's  operation  for  femoral  hernia  289 

Copper  sulphate   105 

Coprostasis  complicating  hernia   193 

Cord,   anterior  transplantation  of    ....   219 

injuries   of    169 

posterior  transplantation  of 203 

transplantation   of    203 

Corrosive  sublimate no 


362 


INDEX 


Cr3'ptorchidism  and  herniotomy 6^ 

Curtis'  operation  for  femoral  hernia.  . .  300 
Cushing's  operation  for  femoral  hernia  289 

Cystitis,  post-operative 168 

Cystocele,  diagnosis  of  difficult 19 

extraperitoneal   crural    346 

Czerny-Banks  method,  results  from  203,  204 
Czerny's  method,  results  from 204 

operation  for  umbilical  hernia  ....   313 

D 

Dauriac's  operation  for  umbilical  hernia  308 

Davis'  operation  for  inguinal  hernia  .  .  260 

Deaver's  operation  for  inguinal  hernia  264 

operation  for  umbilical  hernia  ....   308 
De  Garmo's  operation  for  femoral  her- 
nia    298 

Dentu's   operation   for   inguinal  hernia.  260 

Diaphragm,  hernial  openings  in 323 

Disinfectants,   chemical    102 

Drainage   137 

Dressing,   removal  of  primary    142 

Dressings,  after  herniotomy 13S 

after  herniotomy  on  children 141 

Duplay  and  Cozin's  operation  for  ingui- 
nal hernia 253 

E 

Electricity  in  hernia 278 

Enterocele -. 20 

partial,  in  a  male  336 

Enterostomy  for  tympanites  163 

Eserine  salicylate  in  peritonitis    1S4 

Exudates,  traumatic 173 

F 

Fabricius'  operation  for  femoral  hernia  290 
Fallopian  tube  and  ovary,  hernia  of  ... .     25 

hernia  of   25,  26 

Fasting,   prolonged,  before  herniotomy  313 
Ferguson's   anatomic   operation    in    in- 
guinal hernia 280' 

method,  complications  following  .  .   220 

method,  results  from  215 

operation   for   femoral  hernia    ....   289 

Fever,  primary   187 

secondary 187 

Filigree,  Bartlett's    315,  316 

for  closing  wound 315 

Meyer's   315 

Phelps'  315 

fecal 192 

Fistula,   urinary    192 

Formaldehyde   105 

Fowler's  operation  for  inguinal  hernia  234 
Freeman's  operation  for  inguinal  hernia  268 
Frey's  method,  results  from 203,  204 

Q 

Gauze,  sterilized,  preparation  of  54 

Gersuny's  operation  for  umbilical  her- 
nia     313 

Girard's  operation  for  inguinal  hernia  238 


Gloves,  rubber  121 

rubber,  when  should  be  worn 122 

Glycosuria,  temporary,  in  hernia 193 

eraser's  operation  for  umbiHcal  hernia  310 
Gratschoff's  operation  for  inguinal  her- 
nia      27.^ 

H 

Halsted's  method,  results  from   207 

operation  for  inguinal  hernia   ....   230 

Hammesfahr's    operation    for    femoral 
hernia    303 

Hands,  care  of  119 

chlorinated  lime  in  disinfection  of  121 

disinfection  of   ■  •57-   116 

disinfection  of  by  permanganate  of 

potash  and  oxalic  acid  121 

Fiirbinger's  method  of  disinfecting  121 
Kocher's  method  of  disinfecting  . .  .  12a 
Pearson's  method  of  disinfecting    .  120 

Harrington's  solution   105. 

solution,  preparation  of   54 

Harris'  wire  suture  operation  in  ingui- 
nal  hernia    270 

Heat,  sterilization  by   100 

Hematemesis   159 

Hemophilia  and  herniotomy 32- 

Hemorrhage,  capillary   154 

capillary   control   of 157 

control  of 40,  134 

from  vessels  of  cord  154 

primary    154 

secondary 157 

treatment  of  persistent   from   loop 
of  bowel    157 

Hernia,  absence  of  internal  ring  in...    196- 

anterior 14 

cecal,  complicated  by  hydrocele  and 

appendicitis  346 

classification  of  abdominal   13 

classification  of  femoral 14 

classification  of  inguinal 14 

clinical   varieties   of    16 

condition  of  sac  in  15. 

congenital  diaphragmatic   .321,  322,  323 

congenital  lateral  ventral 344 

contents  of  sac  of  15 

diaphragmatic    318,   322 

diaphragmatic,  indications  for  oper- 
ation      66 

diaphragmatic,      results      following 

operation  on 323. 

diaphragmatic,  traumatic   346 

direct  inguinal,  indications  for  op- 
eration        64: 

displaced  strangulated  femoral  ....   341 

en  bissac   9,   196 

enormous  ventral   350 

epigastric,  indications  for  operation  65 
femoral,  indications  for  operation  .  65 
femoral,  radical  cure  of 289 


INDEX 


Z^2> 


femoral,   results   of   operation   for. 

202,    208 

following  vasectomy   350 

frequency  of  occurrence  in  sexes.  .      10 

funicular,  of  small   intestine    354 

ileo-cecal  334 

ileo-colic ^iZi 

indications  for  operation   32 

inferior    15 

influence   of   intra-abdominal   pres- 
sure in   10 

inguinal,  following  trauma   353 

inguinal,    of    ovary,    appendix    and 

Meckel's  diverticulum 346 

inguinal,  recurrence  after  operation  214 
inguinal,    results    of   operation    for 

202,  208 

inguinal,  without  sac 22 

inguino-interstitial   350 

inguino-properitoneal 349 

in  infants 343 

internal 15 

intersigmoid   330 

interstitial 339,   340 

into  duodeno-jejunal  fossa  324 

into   paraduodenal  fossa    349 

lateral    15 

Littre's,  of  cecum 21 

meso-colic   330 

mortality  of  radical  operations   . .  . 

210,  213,  214 

oblique  inguinal,  indications  for  op- 
eration        58 

of  bladder  and  oviduct 346 

of  cecum   22 

of  Fallopian  tube   26 

of  female  pelvic  organs   25 

of   Meckel's   diverticulum    22 

of  non-gravid  uterus    25 

of  ovary    26 

of  ovary  and  tube   25 

of  ovary  without  tube 25 

of  pancreas    22,   25 

of  pelvic  floor   335 

of  pregnant  uterus    25 

of  seminal  vesicles  25 

of  tube  without  ovary   25 

of   uterus    29 

of   vagina    29 

peritonitis  complicating   174 

posterior   14 

prevalence  of 10 

properitoneal 339,  340,  349 

retroperitoneal    349 

Richter's   349 

strangulated   336 

strangulated  duodenal 342 

strangulated  obturator   342 

strangulated  rectocecal  345 

strangulated,    results    of    operation 
for 209,  210 


strangulation  caused  by  volvulus  .  340 
strangulation   of  as   indication   for 

operation  33 

suppuration  in  wound  as  cause  of 

relapse : 32 

strangulation  of  umbilical 341 

subcecal    334 

superior  15 

through  Douglas'  cul  de  sac  .  .345,  353 
through   foramen   of  Winslow    .  . .   328 
through  mesentery  of  Meckel's  di- 
verticulum     345 

through  rupture  of  rectum   345 

traumatic    9 

traumatic  epigastric  353 

umbilical,  containing  congenital  di- 
verticulum     349 

umbilical,  indications  for  operation  64 
umbilical,     perforating     abdominal 

wall    346 

unique  case  of  femoral 22 

unusual   forms  of    345 

ventral,  indications  for  operation  .  ..  65 
ventral,  results  of  operation  for.  .  208 
vesical,  indications  for  operation  .  .     66 

vesico-rectal 354 

Hernias,  'eponymic   16 

following   appendectomy    65 

inferior,    indications    for   operation     66 

internal  and  inferior  324 

internal,   indications    for   operation     66 

multiple   354 

operated  on  by  laparotomy 313 

Herniotomy  and  alcohohsm   34 

and    appendectomy   combined    ....   254 

and  constitutional  diseases   2>7 

and  cryptorchidism    63 

and  mental  conditions  2>7 

and  obesity  60 

and  occupation   59 

and  syphilis    37 

and  tuberculosis    34 

bicycling  after   279 

cutaneous  compHcations  following.    164 

electricity  for  cure  of  278 

femoral,   Baldwin's   method    290 

femoral,   Ball's   method    289 

femoral,  Banks'  method 289 

femoral,  Barker's  method   289 

femoral,  Bassini's  method   290 

femoral,  Coley's  method    300 

femoral.  Cooper's  method   289 

femoral,   Curtis'   method    300 

femoral,  Cushing's  method   289 

femoral,  De  Garmo's  method    ....   298 

femoral,   Fabricius'   method    290 

femoral,  Ferguson's  method 289 

femoral,  Hammesfahr's  method  . . :  303 

femoral,   Herzen's   method    299 

femoral,  Houston's  method   289 

femoral,  Kammerer's   method    ....   294 


36^ 


I  ?s"  DEX 


femoral,  Lotheissen's  method 300 

femoral,   Macewen's   method    289 

femoral,   jNIarcy's  method    289 

femoral,  McBurne3''s  method   289 

femoral,    Mikulicz's    method    294 

femoral,  Nicoll's  method  297 

femoral,  Ochsner's  method   299 

femoral,    Poh'a's   method 293 

femoral,  Schwartz's  method   303 

femoral,   Socin's  method   300 

femoral,   Sprengel's  method    303 

indications    for    58 

indications  for  immediate 63 

influence  of  age  on ^t, 

influence  of  habits  and  disease  on.     34 

influence  of  sex  on 34 

inguinal,       Andrews"       imbrication 

method  267 

inguinal.   Ball's  method    250 

inguinal,  Barnhill's  method 263 

inguinal,   Bassini's  method    229 

inguinal.   Beck's   method    242 

inguinal,  Benjamin's  method   246 

inguinal,   Bishop's  method    259 

inguinal,  Butler's  method ■.  258 

inguinal,  Davis'  method  260 

inguinal,    Deaver's    method 264 

inguinal,   Dentu's  method    260 

inguinal,  Duplay  and  Cozin's  meth- 
od       253 

inguinal,        Ferguson's        anatomic 

method    280 

inguinal.  Fowler's  method  234 

inguinal.    Freeman's   method    268 

inguinal,  Girard's  method   238 

inguinal,   Gratschoff's  method    ....   274 

inguinal,  Halsted's  method   230 

inguinal,  Harris'  wire  suture  meth- 
od       270 

inguinal.  Herring's  metho-d 245 

inguinal.  Hoffman's  method   280 

inguinal,  Kennedy's  method   260 

inguinal,  Kocher's  method    230 

inguinal,  Lanphear's  method    237 

inguinal,   Leving's   method    250 

inguinal,  ]\Iacewen's  method 225 

inguinal,     McArthur's     autoplastic 

suture  in   269 

inguinal,  Nicholl's  method    242 

inguinal,  Noble's  overlapping  meth- 
od       267 

inguinal,  Owen's  method  263 

inguinal.   Park's   auto-suture  meth- 
od    23S 

inguinal,  Phelps'  silver  wire  meth- 
od       278 

inguinal,   Poullet's  method    253 

inguinal,    Schwartz's    method    ....   249 

inguinal.   Smith's  method    259 

inguinal,  Stinson's  method   245 

inguinal,   Symonds'  method    254 


inguinal,   Torek's  method    254 

inguinal,  Treves'  method 259 

inguinal,  White's  method 259 

inguinal,   Woelfler's   method    249 

inguinal,    Wullstein's    method    ....    241 

in  hospital 80 

intestinal   complications   following.    166 

in   the   home 79 

intraperitoneal    254 

local  anesthesia  in   358 

materials  used  by  author   45 

permanent   results  of 213 

preparation  of  patient  for 38 

pulmonary  complications  of 191 

radical,  general  discussion  of   ....   282 

renal  complications  of   191 

results  of 202 

shock   following    49 

special  instruments  for 44 

umbilical,  Blake's  method   307 

umbilical,  Boeckel's  method 308 

umbilical,    Champonniere's    method  313 
umbilical,  Condamin's  method   ....   313 

umbilical,   Czerny's  method    313 

umbilical,   Dauriac's   method    308 

umbilical,  Deaver's  method  30S 

umbilical,   Gersuny's  method    313 

umbilical,    Graser's   method    310 

umbilical,  Mayo's  method   304 

umbilical,  radical  cure  of  304 

umbilical,   Ransohoff's   method    .  .  .   309 

umbilical,  Reverdin's  method  313 

umbilical,  Terrier's  method 3^3 

umbilical,  Warren's  method   309 

umbilical,  Winslow's  method 309 

vesical   complications   in    167 

vomiting  during   158 

when  should  not  be  performed.  .  .3^,  34 
Herring's   operation    for   inguinal   her- 
nia ■  ■ • 245 

Herzen's  operation  for  femoral  hernia.   299 
Hesselbach,  triangle  of,  methods  of  pro- 
tecting   219 

Hoffman's  operation   for  inguinal  her- 
nia     280 

Horsehair,  preparation  of  .  . ., 50 

Hospital,  service  staff  in  57 

Houston's  operation  for  femoral  hernia  289 

Hydrocele  following  herniotomy 171 

of  canal  of  Nuck 198 

Hydrogen  peroxide  ' 1 16 

I 

Ileus   166 

due  to  tympanites    173 

Immunity 98 

Incision  for  herniotomy 132 

how  to  make   133 

Infection 89 

following  herniotomy    84,  171 

mixed    89 


INDEX 


36  = 


obscure  sources  of  97 

predisposition   to    98 

terminal 89 

Instruments,   disinfection   of 102 

special   for   herniotomy    44 

sterilization  by  heat    102 

used  in  hernia  operations   39 

Intestine,  agglutination  of  173 

pathologic   conditions   of   following 

herniotomy   166 

rejection  of  gangrenous  during  her- 
niotomy     336 

strangulation  of  following  peritoni- 
tis    183 

stricture  of  in  strangulated  hernia.  197 

Intoxication,   septic    187 

Iodine  as   a  disinfectant    iTj. 

Iodoform  115 

emulsion,  preparation  of   53 

gauze,    preparation    of     53 

K 

Kammerer's  operation  for  femoral  her- 
nia       294 

Kennedy's  operation   for  inguinal  her- 
nia       260 

Koch's  law   90 

Kocher's  method,   results   from.... 204,  208 
operation   for  inguinal  hernia    ....   230 

L 

Lanphear's  operation  for  inguinal  her- 
nia     237 

Laparotomy,  indications  for   314 

Lavage,  gastric,  for  vomiting 159 

Leving's  operation  for  inguinal  hernia  250 
Liver,  congenital  hernia  of  into  umbili- 
cal cord 22 

Lotheissen's  operation  for  femoral  her- 
nia      300 

Lysol    109 

M 

rvlacewen's  operation  for  femoral  hernia  2S9 
operation  for  inguinal  hernia  ....  225 
Marcy's  operation  for  femoral  hernia.  .  2S9 
Maj^o's'  operation  for  umbilical  hernia  304 
McArthur's  autoplastic  suture  opera- 
tion in  inguinal  hernia   269 

McBurney's  operation  for  femoral  her- 
nia      289 

Meckel's    diverticulum,   hernia   of    ...  .     22 
Mental  conditions  and  herniotomy  ....      '^'j 

Mercury,   biniodide    114 

INIercuric  chloride  as  an  antiseptic  ....    113 

[Meyer's  filigree   315 

[Micrococci,   varieties   of    84 

[Mikulicz's   operation   for   femoral   her- 
nia       294 

N 
[Nephritis,  post-operative    igi 

Nicholl's  operation  for  inguinal  hernia  242 


Xicoll's  operation   for  femoral  hernia.  297 
Noble's  overlapping  operation  for  ingui- 
nal hernia   267 

Nurses,  duties  of  52 

O 

Obesity  and  herniotomy    60 

Occupation   and   herniotomy    59 

Ochsner's  operation  for  femoral  hernia  299 

Omentum,  amputation  of   43 

pathologic  <:onditions  <if    166 

suppurating  mistaken  for  hernia  .  .  198 

Operating  room,  at  home   79 

care   of    ^z 

in  hospital    80 

Operating   sets    54 

Operation,  indications  for 58 

Operator,   the    TJ 

Ovary  and  tube,  hernia  of 25 

hernia  of   25,  26 

Owen's  operation  for  inguinal  hernia  .  .  263 

Oxalic  acid  for  hand  disinfection   ....  121 

P 

Pagenstecher's  thread  as  suture  mate- 
rial      51 

Pain  as  an  indication   for   herniotomy     72 
differentiation  of  causes   of    ....70,   71 

in  hernia  69.  70,  71,  "]! 

in    peritonitis     177 

post-orerative    163 

treatment  of  post-operative 164 

Pancreas,   hernia   of    22,   25 

Park's  auto-suture  operation  for  ingui- 
nal   hernia    238 

Patient,    physical    condition    of    before 

operating    32 

Patient,  preparation  of  for  herniotomy  "^i 

Peritoneum,   injurj-  of    43 

Peritonitis,    immunizing    injections    to 

prevent    - 183 

in    hernia    174 

pneumococcus     184 

post-operative 172- 

symptoms   of    177 

symptoms   of  pneumococcic    184 

traumatic 173 

treatment  of  post-operative 179 

treatment  of  traumatic  174 

Phagocytosis    98 

Phelps'   filigree    315 

silver    wire    operation,   in    inguinal 

hernia    278 

Pleurisy,  post-operative    191 

Pneumonia,  post-operative    191 

Polya's  operation  for  femoral  hernia.  .  293 

Potassiurn  permanganate  115 

Poullet's  operation  for  inguinal  hernia  253 

Pregnane}',  tubal,  within  hernial  sac.  .  25 

Pulse  in  peritonitis   178 

Pvemia 188 


366 


TNDEX 


Pyoktannin  IIS 

Pj'rexia,    post-operative     187 

R 

Ransohoff's  operation  for  umbilical  her- 
nia       309 

Resection,   results    from    213 

Respiration,  artificial,  in  treatrrient  of 
shock   150 

Reverdin's  operation  for  umbilical  her- 
nia    313 

Richter's  hernia    349 

S 

Sac,  contents  of 10 

pathologic  conditions  of   166 

removal  of  in  radical  cure   204 

varieties  of  hernial   9 

Sal-alembroth 114 

Sapremia 89,  188 

Schwartz's  operation  for  femoral  hernia  303 
operation  for  inguinal  hernia    ....   249 

Scrotum,  abscess  of 197 

Septicemia    187,  188 

treatment  of  188 

Service  stafif  in  hospital  .  .  .  . , 57 

Shock,  complicating  herniotomj^   149 

in  peritonitis    17S 

latent    or    delayed    153 

treatment   of    153 

Silk,  as  suture  material 51 

Silkworm  gut,  preparation  of  50 

Silver  nitrate 115 

Skin,  diseases  of  following  herniotomy.  164 
Smith's  operation  for  inguinal  hernia.  .  259 
Socin's  operation  for  femoral  hernia.  .   300 

Spirilla,  varieties  of 85 

Sponges,  use  of 54 

Sprengel's  operation  for  femoral  hernia.  303 

Steam,  sterilization  b\^  loi 

Sterilization,   methods   of    100 

Stinson's  operation  for  inguinal  hernia.   245 

Suppuration  and  bacteria    86 

in  wound  following  herniotomj^  ...     s^ 

Surgerj^,    aseptic    83 

Suture,  Davison's  removable  continu- 
ous       274 

Eastman's  single  tier    277 

Gratschoff's    removable    continuous  277 

Harris   wire    270 

material,  varieties  and  preparation 

of  45 

McArthur's   autoplastic    269 

Park's   autoplastic    238 

removal    of    142 

Witherbee's  removable   274 

Symonds'  operation  for  inguinal  hernia  254 

Seminal  vesicles,  hernia  of  25 

Sex,  influence  of  on  herniotomy 34 

Syphilis    and   herniotomy    t,/ 


T 

Temperature,  changes  in  during  herni- 
otomy      158 

in  peritonitis    178 

Tendon,  obliteration  of  conjoined 197 

Tendons,  preparation  of 49 

Terrier's  operation  for  umbilical  hernia  313 

Testes,  atrophy  of 197,  198 

atrophy  of  following  herniotomy..    171 

sarcoma    of    197 

undescended  in  hernia 197 

Thread,  celluloid,  as  suture  material.  .     51 

linen,  as  suture  material   51 

Thrombophlebitis  of  accessory  veins  of 

cord  complicating  hernia 339 

Torek's  operation  for  inguinal  hernia.   254 
Treves'  operation  for  inguinal  hernia.  .   259 

Tuberculosis   and  herniotomy   34 

Tj-mpanites,   death  from   160 

enterostomy  for    163 

post-operative 160 

treatment  of 163 

Tympany  in  peritonitis 178 

U 

Uterus,  hernia  of  2Q 

hernia  of  non-gravid  25 

hernia  of  pregnant 25 

subperitoneal    fibroma    of    causing 

hernia  of  bladder    19 

V 

Vaginocele    29 

Vomiting,  complicating  herniotomy.  . .  .  158 

gastric  lavage   for    159 

in  peritonitis    .  '. 178 

treatment  of  post-operative 159 

W 

Warren's  operation  for  umbilical  hernia  309 
Weight,  reduction  of  before  herniotomy  313 
White's  operation  for  inguinal  hernia.   259 
Winslow's  operation  for  umbilical  her- 
nia        309 

Wire,  as   suture  material    49 

silver,   in   inguinal  canal    278 

Woelfler's  method,  results  from  202 

operation   for  inguinal  hernia    ....   249 

Wound,  emphysema  of 197 

protection  of  from  injury   ..• 141 

Wounds,   closure  of    134 

healing  of  aseptic .    146 

infection  of  90,  147 

secondary-  secretion  in   146 

sources  of  infection  of   90 

treatment   of    146 

treatment  of  infected    147 

Wullstein's  operation  for  inguinal  her- 
nia     241 


COLUMBIA   UNIVERSITY    LIBRARIES    - 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

11  III        ' 

n  \^5  Jt 

r5#  J2 

JUL  ' 

y    1  /  jT'ij      w\ 

*•  *"     j( 

'    yMk^ 

1 

C28  (757)100M 

RD621 

•  .  F38 

1907 
Ferguson 

The  technic  of  modern  operations 


iARl4 


F3S 
J?D7 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  621  F38  1907  C.I 

The  technic  o'  nnode^"  ope'-ations  for  her 


2002100622 


